Provider Demographics
NPI:1659827707
Name:INTERMOUNTAIN CENTERS FOR HUMAN DEVELOPMENT INC.
Entity Type:Organization
Organization Name:INTERMOUNTAIN CENTERS FOR HUMAN DEVELOPMENT INC.
Other - Org Name:CASA GRANDE
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:520-721-1887
Mailing Address - Street 1:PO BOX 86537
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85754-6537
Mailing Address - Country:US
Mailing Address - Phone:520-721-1887
Mailing Address - Fax:520-721-0069
Practice Address - Street 1:1821 N TREKELL RD STE 1
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-1705
Practice Address - Country:US
Practice Address - Phone:520-426-4289
Practice Address - Fax:520-421-0792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-29
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC7774251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ202452Medicaid
AZOTC7774OtherADHS/BMFL LICENSE