Provider Demographics
NPI:1568158301
Name:PINETOP TREATMENT CENTER LLC
Entity Type:Organization
Organization Name:PINETOP TREATMENT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HABTOM
Authorized Official - Middle Name:H
Authorized Official - Last Name:HADISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-516-4473
Mailing Address - Street 1:PO BOX 2310
Mailing Address - Street 2:
Mailing Address - City:PINETOP
Mailing Address - State:AZ
Mailing Address - Zip Code:85935-2310
Mailing Address - Country:US
Mailing Address - Phone:602-516-4473
Mailing Address - Fax:
Practice Address - Street 1:674 E WHITE MOUNTAIN BLVD SUITE 1
Practice Address - Street 2:
Practice Address - City:PINETOP
Practice Address - State:AZ
Practice Address - Zip Code:85935-8503
Practice Address - Country:US
Practice Address - Phone:602-516-4473
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-14
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)