Provider Demographics
NPI:1497826101
Name:CENTRO DE AMISTAD, INCORPRORADO
Entity Type:Organization
Organization Name:CENTRO DE AMISTAD, INCORPRORADO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:RITA
Authorized Official - Middle Name:
Authorized Official - Last Name:MONROY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-393-3840
Mailing Address - Street 1:2923 N 33RD AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85017-5201
Mailing Address - Country:US
Mailing Address - Phone:602-393-3840
Mailing Address - Fax:602-393-3842
Practice Address - Street 1:8202 S AVENIDA DEL YAQUI
Practice Address - Street 2:
Practice Address - City:GUADALUPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1024
Practice Address - Country:US
Practice Address - Phone:480-839-2926
Practice Address - Fax:480-839-9985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-187251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ125826OtherAHCCCS - GRP BILLER
AZ105842OtherAHCCCS PROVIDER #
AZA000171OtherMHS VENDOR NO.
AZBH-187OtherAZ BH LICENSE #
AZ1062002OtherVALUEOPTIONS BILLING #