Provider Demographics
NPI:1689741357
Name:SOUTHWEST AUTISM RESEARCH AND RESOURCE CENTER
Entity Type:Organization
Organization Name:SOUTHWEST AUTISM RESEARCH AND RESOURCE CENTER
Other - Org Name:SOUTHWEST AUTISM RESEARCH CENTER, PHOENIX AUTISM RESEARCH CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-218-8211
Mailing Address - Street 1:300 N 18TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-4103
Mailing Address - Country:US
Mailing Address - Phone:602-340-8717
Mailing Address - Fax:602-218-8176
Practice Address - Street 1:300 N 18TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-4103
Practice Address - Country:US
Practice Address - Phone:602-340-8717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ825557Medicaid
AZ825557Medicaid