Organization
WESTSIDE BEHAVIORAL HEALTH LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. TII MAMBILLA MD (CEO)
(928) 279-2661
Entity
Organization
Contact information
Practice address
853 PALA MESA DR, KINGMAN, AZ 86409-3923
(928) 279-2661
Mailing address
853 PALA MESA DR, KINGMAN, AZ 86409-3923
(928) 279-2661
Taxonomy
Speciality
Code
Description
License number
State
310400000X
Assisted Living Facility
—
—
3104A0630X
Assisted Living Facility (Behavioral Disturbances)
Primary
—
—
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
—
—
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
—
—
Other
Enumeration date
12/30/2024
Last updated
12/30/2024
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