Provider Demographics
NPI:1386350049
Name:MAKINI MENTAL HEALTH CENTER LLC
Entity type:Organization
Organization Name:MAKINI MENTAL HEALTH CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KIDIAVAYI
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:602-856-6116
Mailing Address - Street 1:8805 N 23RD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-4172
Mailing Address - Country:US
Mailing Address - Phone:602-856-6116
Mailing Address - Fax:602-856-6122
Practice Address - Street 1:8805 N 23RD AVE STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-4172
Practice Address - Country:US
Practice Address - Phone:602-856-6116
Practice Address - Fax:602-856-6122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-26
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty