Provider Demographics
NPI:1992211619
Name:GRANITE MOUNTAIN BEHAVIORAL HEALTH CARE OF AZ, LLC
Entity Type:Organization
Organization Name:GRANITE MOUNTAIN BEHAVIORAL HEALTH CARE OF AZ, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:NICK
Authorized Official - Middle Name:
Authorized Official - Last Name:HERB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-565-2055
Mailing Address - Street 1:2651 N INDUSTRIAL WAY STE B
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-3545
Mailing Address - Country:US
Mailing Address - Phone:602-565-2055
Mailing Address - Fax:866-758-1208
Practice Address - Street 1:8183 E FLORENTINE RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-8481
Practice Address - Country:US
Practice Address - Phone:602-565-2055
Practice Address - Fax:602-565-2055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility