Provider Demographics
NPI:1457130676
Name:KAIROS MOMENT HEALTHCARE AND BEHAVIORAL CLINIC - LLC
Entity type:Organization
Organization Name:KAIROS MOMENT HEALTHCARE AND BEHAVIORAL CLINIC - LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:ADESOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:IZASOMEH
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP - BC
Authorized Official - Phone:602-410-0958
Mailing Address - Street 1:9652 W PATRICK LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-4319
Mailing Address - Country:US
Mailing Address - Phone:602-410-0958
Mailing Address - Fax:
Practice Address - Street 1:9652 W PATRICK LN
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-4319
Practice Address - Country:US
Practice Address - Phone:602-410-0958
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-26
Last Update Date:2024-10-28
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