Provider Demographics
NPI:1861932048
Name:FJCM BEHAVIORAL HEALTHCARE
Entity type:Organization
Organization Name:FJCM BEHAVIORAL HEALTHCARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER/DIRCTOR
Authorized Official - Prefix:
Authorized Official - First Name:FAUSTIN
Authorized Official - Middle Name:BULONGO
Authorized Official - Last Name:KAPELEMBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-643-5723
Mailing Address - Street 1:4730 W SAMANTHA WAY
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-2141
Mailing Address - Country:US
Mailing Address - Phone:602-237-8660
Mailing Address - Fax:
Practice Address - Street 1:2710 E VALENCIA DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-7081
Practice Address - Country:US
Practice Address - Phone:602-268-7024
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FJCM BEHAVIORAL HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ320800000X320800000X
AZ32450000X324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness