Healthcare Provider Details

I. General information

NPI: 1588740930
Provider Name (Legal Business Name): BRIGHTER HEIGHTS ARIZONA, LLC DBA SMOKI TRAIL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2006
Last Update Date: 07/06/2022
Certification Date: 07/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9435 E SMOKI TRAIL
DEWEY AZ
86327-6990
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 928-632-5806
  • Fax:
Mailing address:
  • Phone: 928-777-3280
  • Fax: 928-227-8493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberBH-2163
License Number StateAZ

VIII. Authorized Official

Name: MS. BROOKE WILSON
Title or Position: SENIOR CREDENTIALING SPECIALIST
Credential:
Phone: 928-910-7644