Healthcare Provider Details

I. General information

NPI: 1497826101
Provider Name (Legal Business Name): CENTRO DE AMISTAD, INCORPRORADO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 03/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8202 S AVENIDA DEL YAQUI
GUADALUPE AZ
85283-1024
US

IV. Provider business mailing address

2923 N 33RD AVE
PHOENIX AZ
85017-5201
US

V. Phone/Fax

Practice location:
  • Phone: 480-839-2926
  • Fax: 480-839-9985
Mailing address:
  • Phone: 602-393-3840
  • Fax: 602-393-3842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberBH-187
License Number StateAZ

VIII. Authorized Official

Name: MRS. RITA MONROY
Title or Position: PRESIDENT AND CEO
Credential:
Phone: 602-393-3840