Provider Demographics
NPI:1023471760
Name:THE RIVER SOURCE OUTPATIENT TUSCON
Entity type:Organization
Organization Name:THE RIVER SOURCE OUTPATIENT TUSCON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ACCOUNT MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-413-9860
Mailing Address - Street 1:6700 N ORACLE ROAD
Mailing Address - Street 2:SUITE 121
Mailing Address - City:TUSCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-7733
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6700 N ORACLE ROAD
Practice Address - Street 2:SUITE 121
Practice Address - City:TUSCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-7733
Practice Address - Country:US
Practice Address - Phone:623-277-8385
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE RIVER SOURCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCSLG7586261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder