Provider Demographics
NPI:1972979862
Name:LIFE TRANSFORMATION RECOVERY
Entity Type:Organization
Organization Name:LIFE TRANSFORMATION RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SANCHEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-515-0044
Mailing Address - Street 1:8521 E FLORENTINE RD STE B
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-8954
Mailing Address - Country:US
Mailing Address - Phone:928-515-0044
Mailing Address - Fax:928-433-4977
Practice Address - Street 1:8521 E FLORENTINE RD STE B
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-8954
Practice Address - Country:US
Practice Address - Phone:928-515-0044
Practice Address - Fax:928-433-4977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-14
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC7200261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ083523Medicaid