Provider Demographics
NPI:1962165506
Name:AGAPE HEALING HOUSE, LLC
Entity type:Organization
Organization Name:AGAPE HEALING HOUSE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ARDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:708-932-7557
Mailing Address - Street 1:2735 E MAIN ST STE 9
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-9269
Mailing Address - Country:US
Mailing Address - Phone:480-534-4000
Mailing Address - Fax:
Practice Address - Street 1:2735 E MAIN ST STE 9
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-9269
Practice Address - Country:US
Practice Address - Phone:480-534-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)