Provider Demographics
NPI:1982709770
Name:BOYS & GIRLS CLUB OF BISBEE,AZ,INC
Entity Type:Organization
Organization Name:BOYS & GIRLS CLUB OF BISBEE,AZ,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:RENTERIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-432-3010
Mailing Address - Street 1:405 ARIZONA ST
Mailing Address - Street 2:
Mailing Address - City:BISBEE
Mailing Address - State:AZ
Mailing Address - Zip Code:85603
Mailing Address - Country:US
Mailing Address - Phone:520-432-3010
Mailing Address - Fax:520-432-6903
Practice Address - Street 1:405 ARIZONA ST
Practice Address - Street 2:
Practice Address - City:BISBEE
Practice Address - State:AZ
Practice Address - Zip Code:85603-1503
Practice Address - Country:US
Practice Address - Phone:520-432-3010
Practice Address - Fax:520-432-6903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ892952Medicare ID - Type Unspecified