Provider Demographics
NPI:1942347034
Name:MINGUS MOUNTAIN ESTATE RESIDENTIAL CENTER INC.
Entity Type:Organization
Organization Name:MINGUS MOUNTAIN ESTATE RESIDENTIAL CENTER INC.
Other - Org Name:MINGUS MOUNTAIN ACADEMY
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BANKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-335-2000
Mailing Address - Street 1:PO BOX 26485
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86312-6485
Mailing Address - Country:US
Mailing Address - Phone:602-335-2000
Mailing Address - Fax:
Practice Address - Street 1:8349 EAST SPOUSE DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314
Practice Address - Country:US
Practice Address - Phone:602-335-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-2839101YM0800X
AZBH 2839251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Not Answered251S00000XAgenciesCommunity/Behavioral Health