Provider Demographics
NPI:1083711360
Name:CHICANOS POR LA CAUSA, INC.
Entity Type:Organization
Organization Name:CHICANOS POR LA CAUSA, INC.
Other - Org Name:CORAZON
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDRES
Authorized Official - Middle Name:
Authorized Official - Last Name:CONTRERAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-257-0700
Mailing Address - Street 1:1112 E. BUCKEYE RD.
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85034
Mailing Address - Country:US
Mailing Address - Phone:602-257-0700
Mailing Address - Fax:602-307-9752
Practice Address - Street 1:3639 W. LINCOLN ST.
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85009
Practice Address - Country:US
Practice Address - Phone:602-233-9747
Practice Address - Fax:602-352-5989
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHICANOS POR LA CAUSA INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-20
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-0008320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH-0008OtherLICENSE
AZ590978Medicaid
AZBH-0008OtherLICENSE