Provider Demographics
NPI:1114090925
Name:MINGUS MOUNTAIN ESTATE RESIDENTIAL CENTER INC
Entity Type:Organization
Organization Name:MINGUS MOUNTAIN ESTATE RESIDENTIAL CENTER INC
Other - Org Name:FARRINGTON HOUSE
Other - Org Type:Other Name
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:PO BOX 26485
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86312-6485
Mailing Address - Country:US
Mailing Address - Phone:602-335-2095
Mailing Address - Fax:602-249-1311
Practice Address - Street 1:100 DEWEY ROAD
Practice Address - Street 2:FARRINGTON HOME
Practice Address - City:DEWEY
Practice Address - State:AZ
Practice Address - Zip Code:86327
Practice Address - Country:US
Practice Address - Phone:602-335-2095
Practice Address - Fax:602-249-1311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-11223104A0630X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ497744Medicaid