Provider Demographics
NPI:1750160511
Name:MOGOLLON TREATMENT CENTER
Entity type:Organization
Organization Name:MOGOLLON TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:TYRI
Authorized Official - Middle Name:NORMAN
Authorized Official - Last Name:BLONDAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-516-2414
Mailing Address - Street 1:306 W AERO DR
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-5405
Mailing Address - Country:US
Mailing Address - Phone:602-516-2414
Mailing Address - Fax:
Practice Address - Street 1:5402 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-8107
Practice Address - Country:US
Practice Address - Phone:602-516-2414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOGOLLON TREATMENT CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility