Provider Demographics
NPI:1861042012
Name:INTERMOUNTAIN CENTERS FOR HUMAN DEVELOPMENT
Entity Type:Organization
Organization Name:INTERMOUNTAIN CENTERS FOR HUMAN DEVELOPMENT
Other - Org Name:INTERMOUNTAIN CENTERS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:520-721-1887
Mailing Address - Street 1:PO BOX 86537
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85754-6537
Mailing Address - Country:US
Mailing Address - Phone:520-721-1887
Mailing Address - Fax:520-721-0069
Practice Address - Street 1:401 N BONITA AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85709-5001
Practice Address - Country:US
Practice Address - Phone:520-571-6466
Practice Address - Fax:520-721-0069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-18
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZOTC9948OtherADHS/BMFL LICENSE
AZ146445Medicaid