1932349644 NPI number — NORTHERN ARIZONA SUBSTANCE ABUSE SERVICES

Table of content: (NPI 1932349644)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932349644 NPI number — NORTHERN ARIZONA SUBSTANCE ABUSE SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN ARIZONA SUBSTANCE ABUSE SERVICES
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:
Provider Other Organization Name Type Code:
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:
1932349644
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2101 N 4TH ST STE 215
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLAGSTAFF
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86004-4200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-773-9376
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2101 N 4TH ST STE 215
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLAGSTAFF
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86004-4200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-773-9376
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/20/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ERHART
Authorized Official First Name:
MARY
Authorized Official Middle Name:
ANNETTE
Authorized Official Title or Position:
DIRECTOR/OWNER
Authorized Official Telephone Number:
928-773-9376

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  #BH-1634 , 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: 597908 . This is a "AHCCCS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".