Provider Demographics
NPI:1184866428
Name:OLD PUEBLO COMMUNITY SERVICES
Entity Type:Organization
Organization Name:OLD PUEBLO COMMUNITY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:LITWICKI
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LISAC
Authorized Official - Phone:520-909-4425
Mailing Address - Street 1:4501 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-7015
Mailing Address - Country:US
Mailing Address - Phone:520-909-4425
Mailing Address - Fax:
Practice Address - Street 1:7030 E BROADWAY BLVD STE 250
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-2829
Practice Address - Country:US
Practice Address - Phone:520-909-4425
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH3168251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health