Provider Demographics
NPI:1134457336
Name:RODTREE WEST
Entity Type:Organization
Organization Name:RODTREE WEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/
Authorized Official - Prefix:DR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-690-1643
Mailing Address - Street 1:12379 W CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-4298
Mailing Address - Country:US
Mailing Address - Phone:602-690-1643
Mailing Address - Fax:
Practice Address - Street 1:12379 W CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-4298
Practice Address - Country:US
Practice Address - Phone:602-690-1643
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-27
Last Update Date:2009-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ235Z00000X, 252Y00000X, 253Z00000X, 320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive Care
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No252Y00000XAgenciesEarly Intervention Provider Agency
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ303384Medicaid