1417033630 NPI number — YUMA TREATMENT CENTER 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 1417033630 NPI number — YUMA TREATMENT CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
YUMA TREATMENT CENTER 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:
1417033630
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19401 N CAVE CREEK ROAD
Provider Second Line Business Mailing Address:
#18 ADMINISTRATIVE OFFICE
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85024-1825
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-996-0105
Provider Business Mailing Address Fax Number:
602-996-1915

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1290 W 8TH PLACE
Provider Second Line Business Practice Location Address:
YUMA TREATMENT CENTER
Provider Business Practice Location Address City Name:
YUMA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-344-4310
Provider Business Practice Location Address Fax Number:
928-344-4366
Provider Enumeration Date:
10/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCKINNEY
Authorized Official First Name:
DEBI
Authorized Official Middle Name:
Authorized Official Title or Position:
REGIONAL COORDINATOR
Authorized Official Telephone Number:
602-996-0105

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  BH2472 , 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: AZ10066M . This is a "FDA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 872128 . This is a "AHCCCS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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