Provider Demographics
NPI:1770681926
Name:ARIZONA RESIDENTIAL CARE, LLC
Entity Type:Organization
Organization Name:ARIZONA RESIDENTIAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:O
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-664-5192
Mailing Address - Street 1:PO BOX 77057
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85703-7057
Mailing Address - Country:US
Mailing Address - Phone:520-882-1986
Mailing Address - Fax:520-882-1987
Practice Address - Street 1:2226 N AVENIDA EL CAPITAN
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-5741
Practice Address - Country:US
Practice Address - Phone:520-882-1986
Practice Address - Fax:520-882-1987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH2456320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ891467OtherAHCCCS