Provider Demographics
NPI:1114337565
Name:SKYLINE PROFESSIONAL SERVICES, LLC
Entity Type:Organization
Organization Name:SKYLINE PROFESSIONAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JESUS
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:928-446-7146
Mailing Address - Street 1:3970 W 24TH ST STE 209
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-9263
Mailing Address - Country:US
Mailing Address - Phone:928-446-7146
Mailing Address - Fax:
Practice Address - Street 1:3970 W 24TH ST STE 209
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-9263
Practice Address - Country:US
Practice Address - Phone:928-446-7146
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-06
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDVS0017251S00000X
AZDUI0024251S00000X
NMLISAC-10172251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health