Provider Demographics
NPI:1750485033
Name:RED MOUNTAIN RESPITE, LLC
Entity type:Organization
Organization Name:RED MOUNTAIN RESPITE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROMUALDO
Authorized Official - Middle Name:R
Authorized Official - Last Name:MUNOZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-641-9552
Mailing Address - Street 1:1223 S CLEARVIEW AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-3306
Mailing Address - Country:US
Mailing Address - Phone:480-641-9552
Mailing Address - Fax:480-981-0893
Practice Address - Street 1:1329 S ROSEANN
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-3739
Practice Address - Country:US
Practice Address - Phone:480-641-9552
Practice Address - Fax:480-981-0893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCSA05ADHS0180385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0093862302Medicaid