MEDICARE: SUPPORTED LIVING SYSTEMS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	BH-1883	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	593493	OTHER	AZ	AHCCS PROVIDER #
2	BH-1883	OTHER	AZ	AZ BEHAVIORAL LICENSE #

General Provider Information

NPI Number	:	1093864340
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPPORTED LIVING SYSTEMS

Provider Business Mailing Address
First Line	:	925 S CRAYCROFT RD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85711-7112
Country	:	US
Telephone Number	:	520-514-9888
Fax Number	:	520-514-9878

Provider Business Practice Location Address
First Line	:	5120 E ALBERTA DR
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85711-3119
Country	:	US
Telephone Number	:	520-514-7840
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. RICHARD ECK
Credential	:	PHD
Telephone Number	:	520-514-9888

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	08/22/2020

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Directions to “SUPPORTED LIVING SYSTEMS ” Practice Location

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