Organization
JANELLE HULTMAN
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JANELLE EVONNE HULTMAN (ADMINISTRATOR)
(623) 581-5687
Entity
Organization
Contact information
Practice address
13401 W FARGO DR, SURPRISE, AZ 85374-5205
(623) 581-5687
Mailing address
13401 W FARGO DR, SURPRISE, AZ 85374-5205
(623) 581-5687
Taxonomy
Speciality
Code
Description
License number
State
3104A0625X
Assisted Living Facility (Mental Illness)
Primary
BH-2695
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
118632
—
AZ
01
—
BH-2695
STATE LICENSE
AZ
Enumeration date
01/26/2007
Last updated
08/22/2020
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