Provider Demographics
NPI:1003060534
Name:SEQUELCARE OF ARIZONA, LLC
Entity Type:Organization
Organization Name:SEQUELCARE OF ARIZONA, LLC
Other - Org Name:BLUE RIDGE
Other - Org Type:Other Name
Authorized Official - Title/Position:DEPUTY DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:NADINE
Authorized Official - Middle Name:
Authorized Official - Last Name:RAMIREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:926-777-3280
Mailing Address - Street 1:8603 E. EASTRIDGE DRIVE
Mailing Address - Street 2:STE. A
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314
Mailing Address - Country:US
Mailing Address - Phone:928-777-3280
Mailing Address - Fax:928-778-1252
Practice Address - Street 1:14410 E. BLUE RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:DEWEY
Practice Address - State:AZ
Practice Address - Zip Code:86327
Practice Address - Country:US
Practice Address - Phone:928-632-8078
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-11
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-3197320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
BH3OtherLICENSE NUMBER BH3197
AZ824509Medicaid