Healthcare Provider Details

I. General information

NPI: 1790699502
Provider Name (Legal Business Name): COPPER CANYON RECOVERY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W 4TH ST
CASA GRANDE AZ
85122-4417
US

IV. Provider business mailing address

201 W 4TH ST
CASA GRANDE AZ
85122-4417
US

V. Phone/Fax

Practice location:
  • Phone: 520-251-0088
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL

VIII. Authorized Official

Name: TONY RENELLO
Title or Position: CONSULTANT
Credential:
Phone: 480-606-8602