Provider Demographics
NPI:1528212974
Name:ARIZONA TRAINING PROGRAM @ COOLIDGE
Entity Type:Organization
Organization Name:ARIZONA TRAINING PROGRAM @ COOLIDGE
Other - Org Name:20 SANDSTONE COURT
Other - Org Type:Other Name
Authorized Official - Title/Position:ASST DIR, DIV. OF DEV. DISABILITIES
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-542-6857
Mailing Address - Street 1:1789 W. JEFFERSON STREET
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85005
Mailing Address - Country:US
Mailing Address - Phone:602-542-6857
Mailing Address - Fax:602-364-1322
Practice Address - Street 1:2800 N. HIGHWAY 87
Practice Address - Street 2:
Practice Address - City:COOLIDGE
Practice Address - State:AZ
Practice Address - Zip Code:85228
Practice Address - Country:US
Practice Address - Phone:520-723-4151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-12
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ040048Medicaid