MEDICARE: LDS FAMILY SERVICES

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	870489265A	AZ

General Provider Information

NPI Number	:	1518187160
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LDS FAMILY SERVICES

Provider Business Mailing Address
First Line	:	7055 W BELL RD
Second Line	:	SUITE 21
City	:	GLENDALE
State	:	AZ
Zip	:	85308-8544
Country	:	US
Telephone Number	:	623-878-2037
Fax Number	:	623-878-2302

Provider Business Practice Location Address
First Line	:	7055 W BELL RD
Second Line	:	SUITE 21
City	:	GLENDALE
State	:	AZ
Zip	:	85308-8544
Country	:	US
Telephone Number	:	623-878-2037
Fax Number	:	623-878-2302

Authorized Official
Title or Position	:	AGENCY DIRECTOR
Name	:	MATTHEW G WATSON
Credential	:
Telephone Number	:	623-878-2037

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	06/03/2008

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