1760589204 NPI number — DOUGLAS ARC

Table of content: (NPI 1760589204)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760589204 NPI number — DOUGLAS ARC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOUGLAS ARC
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:
1760589204
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 252
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOUGLAS
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-364-7473
Provider Business Mailing Address Fax Number:
520-364-2236

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
610 9TH STREET
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-364-7473
Provider Business Practice Location Address Fax Number:
520-364-2236
Provider Enumeration Date:
09/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
GARY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
520-364-7473

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 704933 . This is a "AHCCCS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: CSA06ADHS0046 . This is a "AZ BEHAVIORAL HEALTH SERV" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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