Provider Demographics
NPI:1417134933
Name:INTERMOUNTAIN CENTERS FOR HUMAN DEVELOPMENT INC.
Entity Type:Organization
Organization Name:INTERMOUNTAIN CENTERS FOR HUMAN DEVELOPMENT INC.
Other - Org Name:ANGEL HOUSE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:520-721-1887
Mailing Address - Street 1:PO BOX 86537
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85754-6537
Mailing Address - Country:US
Mailing Address - Phone:520-721-1887
Mailing Address - Fax:520-721-0069
Practice Address - Street 1:1310 N SPEEDWAY PL
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-5236
Practice Address - Country:US
Practice Address - Phone:520-731-0635
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-2914322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ305538Medicaid
AZBH2914OtherADHS/BRFL LICENSE