Provider Demographics
NPI:1396253514
Name:MUCO BEHAVIORAL HEALTH RESIDENTIAL HOME 2
Entity type:Organization
Organization Name:MUCO BEHAVIORAL HEALTH RESIDENTIAL HOME 2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DEOGRATIAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BARANSAKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-760-8378
Mailing Address - Street 1:9010 N 63RD DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-4031
Mailing Address - Country:US
Mailing Address - Phone:623-328-5688
Mailing Address - Fax:623-328-5688
Practice Address - Street 1:9010 N 63RD DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-4031
Practice Address - Country:US
Practice Address - Phone:623-328-5688
Practice Address - Fax:623-328-5688
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MUCO BEHAVIORAL HEALTH RESIDENTIAL HOME, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH5344251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health