Provider Demographics
NPI:1235236506
Name:CHICANOS POR LA CAUSA
Entity Type:Organization
Organization Name:CHICANOS POR LA CAUSA
Other - Org Name:PARENTING ARIZONA
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:EDMUNDO
Authorized Official - Middle Name:
Authorized Official - Last Name:HIDALGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-257-0700
Mailing Address - Street 1:1112 E. BUCKEYE RD.
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85034
Mailing Address - Country:US
Mailing Address - Phone:602-257-0700
Mailing Address - Fax:602-307-9752
Practice Address - Street 1:6741 N. 7TH ST.
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014
Practice Address - Country:US
Practice Address - Phone:602-248-0428
Practice Address - Fax:602-248-0496
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHICANOS POR LA CAUSA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-20
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-2612261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ003072Medicaid