Provider Demographics
NPI:1083943583
Name:SEQUEL TSI OF ARIZONA, LLC SIERRA VISTA
Entity Type:Organization
Organization Name:SEQUEL TSI OF ARIZONA, LLC SIERRA VISTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BANKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-335-2095
Mailing Address - Street 1:4120 E RAMSEY RD
Mailing Address - Street 2:
Mailing Address - City:HEREFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85615-8917
Mailing Address - Country:US
Mailing Address - Phone:520-378-6466
Mailing Address - Fax:520-378-6553
Practice Address - Street 1:4120 E RAMSEY RD
Practice Address - Street 2:
Practice Address - City:HEREFORD
Practice Address - State:AZ
Practice Address - Zip Code:85615-8917
Practice Address - Country:US
Practice Address - Phone:520-378-6466
Practice Address - Fax:520-378-6553
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SEQUELCARE OF ARIZONA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-11
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility