Provider Demographics
NPI:1205164605
Name:INTERMOUNTAIN CENTERS FOR HUMAN DEVELOPMENT INC.
Entity type:Organization
Organization Name:INTERMOUNTAIN CENTERS FOR HUMAN DEVELOPMENT INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:520-721-1887
Mailing Address - Street 1:PO BOX 86537
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85754-6537
Mailing Address - Country:US
Mailing Address - Phone:520-721-1887
Mailing Address - Fax:520-721-0069
Practice Address - Street 1:TOHONO PLAZA BLDG 4 STE 405 BIA STATE ROUTE 19
Practice Address - Street 2:
Practice Address - City:SELLS
Practice Address - State:AZ
Practice Address - Zip Code:85634
Practice Address - Country:US
Practice Address - Phone:520-721-1887
Practice Address - Fax:520-407-5397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-23
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ508246Medicaid
AZBH5148OtherTRIBAL MOU