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5055 E Broadway Blvd Ste A200 Tucson AZ 85711-3649 | |
| (520) 901-4701 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 5055 E Broadway Blvd Ste A200, Tucson, Arizona |
| Authorized Official Name and Position | Rose Mary Lopez (PRESIDENT AND CEO) |
| Authorized Official Contact | 5207211887 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 86537 Tucson AZ 85754-6537 Ph: (520) 721-1887 | 5055 E Broadway Blvd Ste A200 Tucson AZ 85711-3649 Ph: (520) 901-4701 |
| NPI Number | 1023550910 |
|---|---|
| Provider Enumeration Date | 11/09/2016 |
| Last Update Date | 02/11/2021 |
| Certification Date | 02/11/2021 |
| Medicare PECOS PAC ID | 6901181940 |
|---|---|
| Medicare Enrollment ID | O20170314001246 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1023550910 | NPI | - | NPPES |
| OTC9320 | Other | AZ | BUREAU OF MEDICAL LICENSING |
| 231942 | Medicaid | AZ |
| Provider Name | Comfort D Impraim |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1144610239 PECOS PAC ID: 8820306533 Enrollment ID: I20150930000241 |
| Provider Name | Mahlon Roun |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1871529446 PECOS PAC ID: 0345658035 Enrollment ID: I20210625001684 |
| Provider Name | Donald J Hurst |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1629710579 PECOS PAC ID: 0345783023 Enrollment ID: I20240622000272 |
| Provider Name | Tracy Lynn Tilton |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1952035404 PECOS PAC ID: 7113460726 Enrollment ID: I20240624000776 |
| Provider Name | Melissa Ann Duster |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1669218343 PECOS PAC ID: 1153866991 Enrollment ID: I20240716003800 |
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