Provider Demographics
NPI:1174950471
Name:SOVEREIGN HEALTH OF PHOENIX, INC.
Entity type:Organization
Organization Name:SOVEREIGN HEALTH OF PHOENIX, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OPERATIONS SPECIALIST
Authorized Official - Prefix:MR
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:GIRSKIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-359-8273
Mailing Address - Street 1:PO BOX 5705
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92674-5705
Mailing Address - Country:US
Mailing Address - Phone:949-625-0376
Mailing Address - Fax:949-390-9899
Practice Address - Street 1:111 S HEARTHSTONE WAY
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-5010
Practice Address - Country:US
Practice Address - Phone:949-625-0376
Practice Address - Fax:949-390-9899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-01
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE2005211229320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness