Provider Demographics
NPI:1013103530
Name:LA FRONTERA CENTER, INC.NUEVA VIDA
Entity Type:Organization
Organization Name:LA FRONTERA CENTER, INC.NUEVA VIDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-838-5501
Mailing Address - Street 1:1200 E AJO WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85713-5056
Mailing Address - Country:US
Mailing Address - Phone:520-741-3120
Mailing Address - Fax:520-741-3155
Practice Address - Street 1:1200 E AJO WAY STE 101
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85713-5056
Practice Address - Country:US
Practice Address - Phone:520-741-3120
Practice Address - Fax:520-741-3155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-2923251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZWCFGLMedicare UPIN