Provider Demographics
NPI:1467661470
Name:PASCUA YAQUI TRIBE
Entity type:Organization
Organization Name:PASCUA YAQUI TRIBE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DELEGATED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUERRERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-879-6039
Mailing Address - Street 1:7490 S. CAMINO DE OESTE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85757
Mailing Address - Country:US
Mailing Address - Phone:520-879-6163
Mailing Address - Fax:520-879-6099
Practice Address - Street 1:7572 S KAVA VOO D
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85757-8974
Practice Address - Country:US
Practice Address - Phone:520-879-6163
Practice Address - Fax:520-879-6099
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PASCUA YAQUI TRIBE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-22
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH2114322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ200123Medicaid
AZ716011Medicaid