Provider Demographics
NPI:1891300299
Name:ROUNDSVILLE DRUG AND ALCOHOL TREATMENT OF ARIZONA
Entity Type:Organization
Organization Name:ROUNDSVILLE DRUG AND ALCOHOL TREATMENT OF ARIZONA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:HARRISON
Authorized Official - Last Name:COLCLASURE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-420-3214
Mailing Address - Street 1:110 ROCKY DELLS CIR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86303-5681
Mailing Address - Country:US
Mailing Address - Phone:928-420-3214
Mailing Address - Fax:
Practice Address - Street 1:610 N BAGBY DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-2588
Practice Address - Country:US
Practice Address - Phone:928-848-2941
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty