MEDICARE: TUCSON TRANSITIONAL LIVING LLC

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	03D2042651	OTHER	AZ	CLIA LICENSE

General Provider Information

NPI Number	:	1457604126
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TUCSON TRANSITIONAL LIVING LLC

Provider Business Mailing Address
First Line	:	1900 W SAGE ST
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85704-2264
Country	:	US
Telephone Number	:	954-746-8232
Fax Number	:	954-746-8981

Provider Business Practice Location Address
First Line	:	1309 N VENICE AVE
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85712-3935
Country	:	US
Telephone Number	:	954-746-8232
Fax Number	:	954-746-8981

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	MRS. NEISHA ZAFFUTO
Credential	:
Telephone Number	:	954-746-8232

Provider Enumeration Date	:	10/18/2012
Last Update Date	:	06/30/2014

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