Provider Demographics
NPI:1912209859
Name:MARY'S MISSION & DEVELOPMENTAL CENTER, INC.
Entity Type:Organization
Organization Name:MARY'S MISSION & DEVELOPMENTAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:LACEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MBA
Authorized Official - Phone:520-417-2115
Mailing Address - Street 1:345 TAYLOR DR
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-3801
Mailing Address - Country:US
Mailing Address - Phone:520-417-2115
Mailing Address - Fax:520-417-2114
Practice Address - Street 1:736 N COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-4936
Practice Address - Country:US
Practice Address - Phone:520-417-2115
Practice Address - Fax:520-417-2114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-29
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-3732251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ787848OtherAHCCCS