Provider Demographics
NPI:1013065416
Name:SUPPORTED LIVING SYSTEMS
Entity Type:Organization
Organization Name:SUPPORTED LIVING SYSTEMS
Other - Org Name:PIMA HOUSE
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:ECK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:520-514-9888
Mailing Address - Street 1:925 S CRAYCROFT RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-7112
Mailing Address - Country:US
Mailing Address - Phone:520-514-9888
Mailing Address - Fax:520-514-9878
Practice Address - Street 1:3327 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-5858
Practice Address - Country:US
Practice Address - Phone:520-318-0270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-1575322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ434556OtherAHCCS PROVIDER#
AZBH-1575OtherAZ BEHAVIORAL LICENSE #