Provider Demographics
NPI:1649014077
Name:TERRA MEDICAL OF ARIZONA LLC
Entity type:Organization
Organization Name:TERRA MEDICAL OF ARIZONA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:APPLETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-618-3756
Mailing Address - Street 1:65 N POTTEBAUM RD
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-5326
Mailing Address - Country:US
Mailing Address - Phone:602-618-3756
Mailing Address - Fax:
Practice Address - Street 1:1297 E AVENIDA KINO
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-1011
Practice Address - Country:US
Practice Address - Phone:520-709-1586
Practice Address - Fax:602-235-0405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH10111OtherFACILITY LICENSE
AZBH6760OtherFACILITY LICENSE
AZBH10112OtherFACILITY LICENSE