Provider Demographics
NPI:1790015428
Name:SEQUEL TSI OF AZ, LLC
Entity Type:Organization
Organization Name:SEQUEL TSI OF AZ, LLC
Other - Org Name:TRADITIONS TUBA CITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BANKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-335-2095
Mailing Address - Street 1:PO BOX 2257
Mailing Address - Street 2:
Mailing Address - City:TUBA CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86045-2257
Mailing Address - Country:US
Mailing Address - Phone:928-283-6808
Mailing Address - Fax:928-283-6848
Practice Address - Street 1:75 S. MAIN ST., SUITE B
Practice Address - Street 2:KENTUCKY FRIED CHICKEN COMPLES
Practice Address - City:TUBA CITY
Practice Address - State:AZ
Practice Address - Zip Code:86045
Practice Address - Country:US
Practice Address - Phone:928-283-6808
Practice Address - Fax:928-283-6848
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SEQUELCARE OF AZ, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-31
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health