Provider Demographics
NPI:1689913527
Name:MIRASOL, INC.
Entity Type:Organization
Organization Name:MIRASOL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:LESTER
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:520-546-3200
Mailing Address - Street 1:2954 N CAMPBELL AVE # 157
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-2813
Mailing Address - Country:US
Mailing Address - Phone:520-546-3200
Mailing Address - Fax:520-546-3205
Practice Address - Street 1:3116 N SWAN RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-1227
Practice Address - Country:US
Practice Address - Phone:520-546-3200
Practice Address - Fax:520-546-3205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-13
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC 6713261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health