Provider Demographics
NPI:1407040553
Name:MIRASOL INC
Entity type:Organization
Organization Name:MIRASOL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUST
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:520-546-3200
Mailing Address - Street 1:2954 N CAMPBELL AVE # 157
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-2813
Mailing Address - Country:US
Mailing Address - Phone:520-546-3200
Mailing Address - Fax:
Practice Address - Street 1:1515 E KLEINDALE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-1915
Practice Address - Country:US
Practice Address - Phone:520-546-3200
Practice Address - Fax:520-546-3205
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIRASOL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-31
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH 4518323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility