Provider Demographics
NPI:1275860702
Name:SEQUELCARE OF ARIZONA, LLC
Entity Type:Organization
Organization Name:SEQUELCARE OF ARIZONA, LLC
Other - Org Name:TAP PROGRAM MESA
Other - Org Type:Other Name
Authorized Official - Title/Position:DEPUTY DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:NADINE
Authorized Official - Middle Name:
Authorized Official - Last Name:RAMIREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-777-3280
Mailing Address - Street 1:8603 E. EASTRIDGE DRIVE
Mailing Address - Street 2:STE. A
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314
Mailing Address - Country:US
Mailing Address - Phone:928-777-3280
Mailing Address - Fax:928-778-1252
Practice Address - Street 1:450 WEST 5TH PLACE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201
Practice Address - Country:US
Practice Address - Phone:480-429-4126
Practice Address - Fax:480-429-4126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-04
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-3441251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ476231Medicaid
AZBH-3441OtherOBHL LICENSE