1114492766 NPI number — ARIZONA BEHAVIORAL CARE HOMES LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114492766 NPI number — ARIZONA BEHAVIORAL CARE HOMES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ARIZONA BEHAVIORAL CARE HOMES LLC
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:
1114492766
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/10/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4645 S LAKESHORE DR STE 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEMPE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85282-7152
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-840-1601
Provider Business Mailing Address Fax Number:
480-840-1613

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
613 W DEVON CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85233-8029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-840-1601
Provider Business Practice Location Address Fax Number:
480-840-1613
Provider Enumeration Date:
10/10/2018

Additional Information

Authorized Official

Authorized Official Last Name:
BREEDLOVE
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
CRAWFORD
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
480-840-1601

Provider Taxonomy Codes

  • Taxonomy code: 320800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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