Provider Demographics
NPI:1174154827
Name:SOUL SURGERY SILKWORTH CENTER LLC
Entity type:Organization
Organization Name:SOUL SURGERY SILKWORTH CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAKESPEARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-554-5633
Mailing Address - Street 1:PO BOX 12434
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85267-2434
Mailing Address - Country:US
Mailing Address - Phone:480-912-3105
Mailing Address - Fax:480-912-3106
Practice Address - Street 1:16433 N 68TH PL
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-1500
Practice Address - Country:US
Practice Address - Phone:480-912-3105
Practice Address - Fax:480-477-7894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility