Provider Demographics
NPI:1467654814
Name:MINGUS MOUNTAIN ESTATE RESIDENCIAL CENTER, INC.
Entity Type:Organization
Organization Name:MINGUS MOUNTAIN ESTATE RESIDENCIAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BANKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-335-2000
Mailing Address - Street 1:PO BOX 26485
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86312-6485
Mailing Address - Country:US
Mailing Address - Phone:602-335-2000
Mailing Address - Fax:602-249-1311
Practice Address - Street 1:HC 76 HWY 89 A N JUNCTION 151
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86312-6485
Practice Address - Country:US
Practice Address - Phone:602-335-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-14873104A0630X
AZBH-312322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
Not Answered322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ590118Medicaid
AZ497744Medicaid
AZ498057Medicaid