1073684791 NPI number — CENTRO DE AMISTAD, INCORPORADO

Table of content: (NPI 1073684791)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073684791 NPI number — CENTRO DE AMISTAD, INCORPORADO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRO DE AMISTAD, INCORPORADO
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:
1073684791
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2923 N 33RD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85017-5201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-393-3840
Provider Business Mailing Address Fax Number:
602-393-3842

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
460 N MESA DR STE 115
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85201-5974
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-833-0227
Provider Business Practice Location Address Fax Number:
480-655-1382
Provider Enumeration Date:
11/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MONROY
Authorized Official First Name:
RITA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT AND CEO
Authorized Official Telephone Number:
602-393-3840

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  BH-2632 , 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: 1062003 . This is a "VO BILLING NUMBER" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 116906 . This is a "AHCCCS PROVIDER #" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: A000173 . This is a "MHS VENDOR NO." identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: BH-2632 . This is a "AZ BH LICENSE NO" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 600252351 . This is a "MAGELLAN MIS#" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: BH-3610 . This is a "AZ BH LINENCE #" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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