Provider Demographics
NPI:1588426266
Name:LIVING HOPE CLINIC LLC
Entity type:Organization
Organization Name:LIVING HOPE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:NIZEYE
Authorized Official - Last Name:JENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-699-6134
Mailing Address - Street 1:5251 W CAMPBELL AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85031-1719
Mailing Address - Country:US
Mailing Address - Phone:207-966-6134
Mailing Address - Fax:
Practice Address - Street 1:5251 W CAMPBELL AVE STE 208
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85031-1719
Practice Address - Country:US
Practice Address - Phone:207-966-6134
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health