Provider Demographics
NPI:1356358519
Name:MINGUS MOUNTAIN ESTATE RESIDENTIAL CENTER INC
Entity type:Organization
Organization Name:MINGUS MOUNTAIN ESTATE RESIDENTIAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:COPAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-335-2000
Mailing Address - Street 1:2517 N GREAT WESTERN DR STE P
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-2597
Mailing Address - Country:US
Mailing Address - Phone:602-335-2068
Mailing Address - Fax:602-335-2066
Practice Address - Street 1:15801 E DON CARLOS DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86315-4109
Practice Address - Country:US
Practice Address - Phone:602-335-2068
Practice Address - Fax:602-335-2066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-312322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children