Provider Demographics
NPI:1467661470
Name:PASCUA YAQUI TRIBE
Entity Type:Organization
Organization Name:PASCUA YAQUI TRIBE
Other - Org Name:YOEME KARI GROUP HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:M
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-879-6163
Mailing Address - Street 1:7490 S. CAMINO DE OESTE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85757
Mailing Address - Country:US
Mailing Address - Phone:520-879-6163
Mailing Address - Fax:520-879-6099
Practice Address - Street 1:2861 W VIA HACIENDA
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-3424
Practice Address - Country:US
Practice Address - Phone:520-879-6163
Practice Address - Fax:520-879-6099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH2114322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ218075Medicaid
AZ716011Medicaid