Provider Demographics
NPI:1336454867
Name:THE RIVER SOURCE
Entity Type:Organization
Organization Name:THE RIVER SOURCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:WESTBROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-206-3999
Mailing Address - Street 1:108 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-1410
Mailing Address - Country:US
Mailing Address - Phone:888-687-7332
Mailing Address - Fax:480-827-1637
Practice Address - Street 1:108 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-1410
Practice Address - Country:US
Practice Address - Phone:888-687-7332
Practice Address - Fax:480-827-1637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-09
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-3428324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility