Provider Demographics
NPI:1467523183
Name:CENTRO DE AMISTAD, INCORPORADO
Entity Type:Organization
Organization Name:CENTRO DE AMISTAD, INCORPORADO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:RITA
Authorized Official - Middle Name:
Authorized Official - Last Name:MONROY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-839-2926
Mailing Address - Street 1:8202 S AVENIDA DEL YAQUI
Mailing Address - Street 2:
Mailing Address - City:GUADALUPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-1024
Mailing Address - Country:US
Mailing Address - Phone:480-839-2926
Mailing Address - Fax:480-839-9985
Practice Address - Street 1:2923 N 33RD AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-5201
Practice Address - Country:US
Practice Address - Phone:602-393-3840
Practice Address - Fax:602-393-3842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-3759251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1062007OtherVO BILLING NUMBER
AZ957409OtherAHCCCS PROVIDER NO.
AZBH-2504OtherAZ BH LICENSE NO.
AZ600252357OtherMAGELLAN MIS#
AZA004334OtherMHS VENDOR NO.