Provider Demographics
NPI:1073349874
Name:NEW MERVEILLE 2 LLC
Entity type:Organization
Organization Name:NEW MERVEILLE 2 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DESIRE
Authorized Official - Middle Name:N
Authorized Official - Last Name:NKOMEZI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:817-707-2798
Mailing Address - Street 1:4821 N 108TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-5471
Mailing Address - Country:US
Mailing Address - Phone:817-707-2798
Mailing Address - Fax:
Practice Address - Street 1:4821 N 108TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-5471
Practice Address - Country:US
Practice Address - Phone:817-707-2798
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-10
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No251S00000XAgenciesCommunity/Behavioral Health
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children