Provider Demographics
NPI:1093810889
Name:LA FRONTERA CENTER, INC.
Entity Type:Organization
Organization Name:LA FRONTERA CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-838-5501
Mailing Address - Street 1:502 W 29TH ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85713-3353
Mailing Address - Country:US
Mailing Address - Phone:520-838-3901
Mailing Address - Fax:520-792-0654
Practice Address - Street 1:502 W 29TH ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85713-3394
Practice Address - Country:US
Practice Address - Phone:520-884-9920
Practice Address - Fax:520-792-0654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-102261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ069139Medicaid
AZZWCFGLMedicare ID - Type Unspecified