Provider Demographics
NPI:1891025524
Name:SEQUEL TSI OF AZ, LLC
Entity Type:Organization
Organization Name:SEQUEL TSI OF AZ, LLC
Other - Org Name:TRADITIONS WHITERIVER
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 1:1109 S. CHIEF AVE.
Mailing Address - Street 2:WHITE MOUNTAIN APACHE MOTEL.
Mailing Address - City:WHITERIVER
Mailing Address - State:AZ
Mailing Address - Zip Code:85941
Mailing Address - Country:US
Mailing Address - Phone:928-338-4927
Mailing Address - Fax:928-338-4742
Practice Address - Street 1:1109 S. CHIEF AVE.
Practice Address - Street 2:WHITE MOUNTAIN APACHE MOTEL.
Practice Address - City:WHITERIVER
Practice Address - State:AZ
Practice Address - Zip Code:85941
Practice Address - Country:US
Practice Address - Phone:928-338-4927
Practice Address - Fax:928-338-4742
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