Healthcare Provider Details

I. General information

NPI: 1114090925
Provider Name (Legal Business Name): MINGUS MOUNTAIN ESTATE RESIDENTIAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 DEWEY ROAD FARRINGTON HOME
DEWEY AZ
86327
US

IV. Provider business mailing address

2517 N GREAT WESTERN DR
PRESCOTT VALLEY AZ
86314-2597
US

V. Phone/Fax

Practice location:
  • Phone: 602-335-2095
  • Fax: 602-249-1311
Mailing address:
  • Phone: 602-335-2000
  • Fax: 480-534-7494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License NumberBH-1122
License Number StateAZ

VIII. Authorized Official

Name: BROOKE WILSON
Title or Position: SENIOR CREDENTIALING SPECIALISTS
Credential:
Phone: 602-335-2000