Provider Demographics
NPI:1760589204
Name:DOUGLAS ARC
Entity Type:Organization
Organization Name:DOUGLAS ARC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-364-7473
Mailing Address - Street 1:PO BOX 252
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:AZ
Mailing Address - Zip Code:85608
Mailing Address - Country:US
Mailing Address - Phone:520-364-7473
Mailing Address - Fax:520-364-2236
Practice Address - Street 1:610 9TH STREET
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:AZ
Practice Address - Zip Code:85607
Practice Address - Country:US
Practice Address - Phone:520-364-7473
Practice Address - Fax:520-364-2236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-19
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ704933OtherAHCCCS
AZCSA06ADHS0046OtherAZ BEHAVIORAL HEALTH SERV