Provider Demographics
NPI:1073684791
Name:CENTRO DE AMISTAD, INCORPORADO
Entity Type:Organization
Organization Name:CENTRO DE AMISTAD, INCORPORADO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:RITA
Authorized Official - Middle Name:
Authorized Official - Last Name:MONROY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-393-3840
Mailing Address - Street 1:2923 N 33RD AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85017-5201
Mailing Address - Country:US
Mailing Address - Phone:602-393-3840
Mailing Address - Fax:602-393-3842
Practice Address - Street 1:460 N MESA DR STE 115
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-5974
Practice Address - Country:US
Practice Address - Phone:480-833-0227
Practice Address - Fax:480-655-1382
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRO DE AMISTAD, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-13
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-2632251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1062003OtherVO BILLING NUMBER
AZ116906OtherAHCCCS PROVIDER #
AZA000173OtherMHS VENDOR NO.
AZBH-2632OtherAZ BH LICENSE NO
AZ600252351OtherMAGELLAN MIS#
AZBH-3610OtherAZ BH LINENCE #