1497826101 NPI number — CENTRO DE AMISTAD, INCORPRORADO

Table of content: (NPI 1497826101)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497826101 NPI number — CENTRO DE AMISTAD, INCORPRORADO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRO DE AMISTAD, INCORPRORADO
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:
1497826101
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2923 N 33RD 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:
85017-5201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-393-3840
Provider Business Mailing Address Fax Number:
602-393-3842

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8202 S AVENIDA DEL YAQUI
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GUADALUPE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85283-1024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-839-2926
Provider Business Practice Location Address Fax Number:
480-839-9985
Provider Enumeration Date:
11/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MONROY
Authorized Official First Name:
RITA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT AND CEO
Authorized Official Telephone Number:
602-393-3840

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  BH-187 , 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: 125826 . This is a "AHCCCS - GRP BILLER" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 105842 . This is a "AHCCCS PROVIDER #" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: A000171 . This is a "MHS VENDOR NO." identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: BH-187 . This is a "AZ BH LICENSE #" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 1062002 . This is a "VALUEOPTIONS BILLING #" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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