Provider Demographics
NPI:1235657461
Name:ARIZONA REHAB CAMPUS, LLC
Entity Type:Organization
Organization Name:ARIZONA REHAB CAMPUS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLAIMS MGR
Authorized Official - Prefix:MS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-526-1028
Mailing Address - Street 1:6944 E TANQUE VERDE RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-5308
Mailing Address - Country:US
Mailing Address - Phone:520-526-1028
Mailing Address - Fax:520-777-5752
Practice Address - Street 1:6944 E TANQUE VERDE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715
Practice Address - Country:US
Practice Address - Phone:623-326-1055
Practice Address - Fax:480-659-1598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-08
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
AZOTC8336261QR0405X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZOTC8336OtherARIZONA STATE LICENSE