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1100 N F Ave Douglas AZ 85607-1919 | |
| (520) 364-3630 | |
| (520) 586-6104 |
| Full Name | |
|---|---|
| Speciality | Community/behavioral Health |
| Location | 1100 N F Ave, Douglas, Arizona |
| Authorized Official Name and Position | Estella Hernandez (CONTRACTS & CREDENTIALING ADMIN) |
| Authorized Official Contact | 5208385513 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
611 W Union St Benson AZ 85602-6718 Ph: (520) 586-0800 | 1100 N F Ave Douglas AZ 85607-1919 Ph: (520) 364-3630 |
| NPI Number | 1578033809 |
|---|---|
| Provider Enumeration Date | 11/29/2018 |
| Last Update Date | 06/10/2022 |
| Certification Date | 06/10/2022 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1578033809 | NPI | - | NPPES |
| 478436 | Medicaid | AZ | |
| OTC-9263 | Other | AZ | ADHS LICENSING |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | (* (Not Available)) | Primary |
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