Provider Demographics
NPI:1245819911
Name:ARIZONA SHALOM CENTER, LLC
Entity type:Organization
Organization Name:ARIZONA SHALOM CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINSTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ETIENNE
Authorized Official - Middle Name:
Authorized Official - Last Name:AHAYO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-358-7189
Mailing Address - Street 1:22453 N VANDERVEEN WAY
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85138-5570
Mailing Address - Country:US
Mailing Address - Phone:480-358-7189
Mailing Address - Fax:
Practice Address - Street 1:22453 N VANDERVEEN WAY
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85138-5570
Practice Address - Country:US
Practice Address - Phone:480-358-7189
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health