Provider Demographics
NPI:1770038564
Name:SOUTH MOUNTAIN HOLISTIC CARE
Entity Type:Organization
Organization Name:SOUTH MOUNTAIN HOLISTIC CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BRIGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-565-5909
Mailing Address - Street 1:3219 W OLNEY AVE
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339
Mailing Address - Country:US
Mailing Address - Phone:602-565-5909
Mailing Address - Fax:
Practice Address - Street 1:3219 W OLNEY AVE
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-1783
Practice Address - Country:US
Practice Address - Phone:602-565-5909
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4914310500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness