1265544324 NPI number — OPEN HEARTS

Table of content: (NPI 1265544324)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265544324 NPI number — OPEN HEARTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPEN HEARTS
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:
YOUTH EVALUATION & TREATMENT CENTERS
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:
1265544324
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4414 N 19TH 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:
85015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-285-5550
Provider Business Mailing Address Fax Number:
602-285-5551

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4414 N 19TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-285-5550
Provider Business Practice Location Address Fax Number:
602-285-5551
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GOMEZ
Authorized Official First Name:
ARJELIA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT & CEO
Authorized Official Telephone Number:
602-285-5550

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  BH-1794 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YA0400X , with the licence number: BH-1794 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: BH-1794 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 104100000X , with the licence number: BH-1794 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 349127 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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