1922190958 NPI number — BRIGHTER HEIGHTS ARIZONA, LLC DBA BLUE RIDGE MANOR

Table of content: (NPI 1922190958)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922190958 NPI number — BRIGHTER HEIGHTS ARIZONA, LLC DBA BLUE RIDGE MANOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIGHTER HEIGHTS ARIZONA, LLC DBA BLUE RIDGE MANOR
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DAYBREAK BEHAVIORAL RESOURCES DBA BLUE RIDGE MANOR
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922190958
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2517 N GREAT WESTERN DR.
Provider Second Line Business Mailing Address:
SUITE P
Provider Business Mailing Address City Name:
PRESCOTT VALLEY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86314-2597
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-777-3280
Provider Business Mailing Address Fax Number:
928-227-8493

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14410 E BLUE RIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEWEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86327-6754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-632-8078
Provider Business Practice Location Address Fax Number:
928-632-8082
Provider Enumeration Date:
09/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
BROOKE
Authorized Official Middle Name:
Authorized Official Title or Position:
SENIOR CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
928-910-7644

Provider Taxonomy Codes

  • Taxonomy code: 322D00000X , with the licence number:  BH-2374 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 824509 . This is a "AHCCCS ID" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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