1205877610 NPI number — CHANGEPOINT INTEGRATED HEALTH

Table of content: (NPI 1205877610)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205877610 NPI number — CHANGEPOINT INTEGRATED HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHANGEPOINT INTEGRATED HEALTH
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:
COMMUNITY COUNSELING CENTERS, INC
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:
1205877610
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1801 W DEUCE OF CLUBS STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHOW LOW
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85901-2704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-537-2951
Provider Business Mailing Address Fax Number:
928-892-5828

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 N 1ST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLBROOK
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86025-2817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-537-2951
Provider Business Practice Location Address Fax Number:
928-892-5828
Provider Enumeration Date:
06/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OAKES
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
928-537-2951

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  OTC6041 , 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: 003450 . This is a "AHCCCS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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