1124016019 NPI number — SOUTHEASTERN ARIZONA BEHAVIORAL HEALTH SERVICES, INC.

Table of content: (NPI 1124016019)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124016019 NPI number — SOUTHEASTERN ARIZONA BEHAVIORAL HEALTH SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEASTERN ARIZONA BEHAVIORAL HEALTH SERVICES, INC.
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:
6
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:
1124016019
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 2161
Provider Second Line Business Mailing Address:
611 W. UNION STREET
Provider Business Mailing Address City Name:
BENSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-586-0800
Provider Business Mailing Address Fax Number:
520-586-0116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1701 N DOUGLAS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOUGLAS
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85607-1019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-364-1286
Provider Business Practice Location Address Fax Number:
520-805-1221
Provider Enumeration Date:
10/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HERNANDEZ
Authorized Official First Name:
ESTELLA
Authorized Official Middle Name:
Authorized Official Title or Position:
CONTRACTS & CREDENTIALING ADMIN
Authorized Official Telephone Number:
520-838-5513

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X , with the licence number:  BH-1896 , 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)





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