Provider Demographics
NPI:1437346517
Name:NORTHWEST ORGANIZATION FOR VOLUNTARY ALTERNATIVES
Entity Type:Organization
Organization Name:NORTHWEST ORGANIZATION FOR VOLUNTARY ALTERNATIVES
Other - Org Name:DBA: MAVERICK HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACTING DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:PINNOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-937-9203
Mailing Address - Street 1:4425 WEST OLIVE AVENUE SUITE 200
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302
Mailing Address - Country:US
Mailing Address - Phone:623-937-9203
Mailing Address - Fax:623-930-0358
Practice Address - Street 1:5801 NORTH 51ST AVENUE SUITE 109
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301
Practice Address - Country:US
Practice Address - Phone:623-931-5810
Practice Address - Fax:623-931-1302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH 406324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ346058OtherAHCCCS