Provider Demographics
NPI:1154826527
Name:VILLA MARIA CARE CENTER, LLC
Entity Type:Organization
Organization Name:VILLA MARIA CARE CENTER, LLC
Other - Org Name:TUCSON RECOVERY VILLA MARIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCNELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-991-9062
Mailing Address - Street 1:4310 E GRANT RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2607
Mailing Address - Country:US
Mailing Address - Phone:520-323-9351
Mailing Address - Fax:
Practice Address - Street 1:4310 E GRANT RD STE A
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2607
Practice Address - Country:US
Practice Address - Phone:520-323-9351
Practice Address - Fax:520-323-6490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH5309324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH5309OtherARIZONA DEPARTMENT OF HEALTH SERVICES