Provider Demographics
NPI:1497167480
Name:THE RIVER SOURCE
Entity Type:Organization
Organization Name:THE RIVER SOURCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:
Authorized Official - Last Name:FERRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-836-2205
Mailing Address - Street 1:950 N ARIZOLA RD STE 3
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-6196
Mailing Address - Country:US
Mailing Address - Phone:520-836-2205
Mailing Address - Fax:
Practice Address - Street 1:950 N ARIZOLA RD STE 3
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-6196
Practice Address - Country:US
Practice Address - Phone:520-836-2205
Practice Address - Fax:520-836-1882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-24
Last Update Date:2014-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13-1381324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility