Provider Demographics
NPI:1043574577
Name:ARROWHEAD LODGE
Entity Type:Organization
Organization Name:ARROWHEAD LODGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:626-797-9977
Mailing Address - Street 1:5113 W ARROWHEAD DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-7304
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5113 W ARROWHEAD DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-7304
Practice Address - Country:US
Practice Address - Phone:626-797-9977
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE MONTANA SOCIETY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-29
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-3965324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility