1801026539 NPI number — MIKID, MENTALLY ILL KIDS IN DISTRESS

Table of content: (NPI 1801026539)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801026539 NPI number — MIKID, MENTALLY ILL KIDS IN DISTRESS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIKID, MENTALLY ILL KIDS IN DISTRESS
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:
1801026539
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2642 E THOMAS RD
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:
85016-8202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-253-1240
Provider Business Mailing Address Fax Number:
602-253-1250

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 E 24TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YUMA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85364-8619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-726-2191
Provider Business Practice Location Address Fax Number:
928-726-4052
Provider Enumeration Date:
07/15/2009

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
VICKI
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
602-253-1240

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  CSA09ADHS0142 -2 , 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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