1992211619 NPI number — GRANITE MOUNTAIN BEHAVIORAL HEALTH CARE OF AZ, LLC

Table of content: (NPI 1992211619)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992211619 NPI number — GRANITE MOUNTAIN BEHAVIORAL HEALTH CARE OF AZ, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRANITE MOUNTAIN BEHAVIORAL HEALTH CARE OF AZ, 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:
1992211619
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/18/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2651 N INDUSTRIAL WAY STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRESCOTT VALLEY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86314-3545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-565-2055
Provider Business Mailing Address Fax Number:
866-758-1208

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8183 E FLORENTINE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRESCOTT VALLEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86314-8481
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-565-2055
Provider Business Practice Location Address Fax Number:
602-565-2055
Provider Enumeration Date:
12/18/2017

Additional Information

Authorized Official

Authorized Official Last Name:
HERB
Authorized Official First Name:
NICK
Authorized Official Middle Name:
Authorized Official Title or Position:
ACCOUNTANT
Authorized Official Telephone Number:
602-565-2055

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , 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)





Copyright © 2007-2025 www.npivalidator.com