Provider Demographics
NPI:1568132959
Name:CACTUS SAGE LLC
Entity Type:Organization
Organization Name:CACTUS SAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MUTWOL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-225-1240
Mailing Address - Street 1:3848 E POLLACK ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-6207
Mailing Address - Country:US
Mailing Address - Phone:623-225-1240
Mailing Address - Fax:
Practice Address - Street 1:1445 E SUNSET DR
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-1785
Practice Address - Country:US
Practice Address - Phone:623-225-1240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH7060OtherAZDHS