Provider Demographics
NPI:1629750005
Name:TORREZ, MARIO
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:TORREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4221 N 31ST ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5818
Mailing Address - Country:US
Mailing Address - Phone:623-695-4064
Mailing Address - Fax:
Practice Address - Street 1:2239 W DANBURY RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-2230
Practice Address - Country:US
Practice Address - Phone:602-603-4717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1235706243Medicaid