Healthcare Provider Details

I. General information

NPI: 1184712143
Provider Name (Legal Business Name): SEQUELCARE OF ARIZONA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 04/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6070 N. TREADWAY TRAIL
FLAGSTAFF AZ
86004
US

IV. Provider business mailing address

8603 E. EASTRIDGE DRIVE STE. A
PRESCOTT VALLEY AZ
86314
US

V. Phone/Fax

Practice location:
  • Phone: 928-526-1499
  • Fax: 928-526-1151
Mailing address:
  • Phone: 928-777-3280
  • Fax: 928-778-1252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberBH-3337
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberBH-3337
License Number StateAZ

VIII. Authorized Official

Name: MRS. NADINE RAMIREZ
Title or Position: DEPUTY DIRECTOR
Credential:
Phone: 928-777-3280