Provider Demographics
NPI:1861932097
Name:SKA-SHIFRA FACILITY
Entity type:Organization
Organization Name:SKA-SHIFRA FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ CEO
Authorized Official - Prefix:
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:KABAMBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-545-0242
Mailing Address - Street 1:7136 N 73RD DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85303-2569
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7136 N 73RD DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85303-2569
Practice Address - Country:US
Practice Address - Phone:203-545-0242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4983320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness