Provider Demographics
NPI:1528330339
Name:MWANGAZA RESIDENTIAL CARE LLC
Entity type:Organization
Organization Name:MWANGAZA RESIDENTIAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JONAH
Authorized Official - Middle Name:KIBITOK
Authorized Official - Last Name:MAIYO
Authorized Official - Suffix:
Authorized Official - Credentials:CEO/PROGRAM DIRECTOR
Authorized Official - Phone:520-248-1295
Mailing Address - Street 1:8618 N WESTERN JUNIPER TER
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85743-7132
Mailing Address - Country:US
Mailing Address - Phone:520-248-1295
Mailing Address - Fax:520-338-2490
Practice Address - Street 1:6330 S KOLB RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85756-9287
Practice Address - Country:US
Practice Address - Phone:520-248-1295
Practice Address - Fax:520-338-2490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-08
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness