Healthcare Provider Details

I. General information

NPI: 1497102495
Provider Name (Legal Business Name): HALLMARK BEHAVIORAL HEALTH @ LAGO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2016
Last Update Date: 02/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

688 S LAGO DR
APACHE JUNCTION AZ
85120-5123
US

IV. Provider business mailing address

1550 E MCKELLIPS RD STE 109
MESA AZ
85203-2753
US

V. Phone/Fax

Practice location:
  • Phone: 480-625-1005
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JEFF TILLEY
Title or Position: MANGAGER
Credential:
Phone: 602-695-4156