Healthcare Provider Details

I. General information

NPI: 1215038757
Provider Name (Legal Business Name): ALTA VISTA GROUP HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4108 E RAMSEY RD
HEREFORD AZ
85615-8917
US

IV. Provider business mailing address

4108 E RAMSEY RD
HEREFORD AZ
85615-8917
US

V. Phone/Fax

Practice location:
  • Phone: 520-378-6466
  • Fax: 520-378-6553
Mailing address:
  • Phone: 520-378-6466
  • Fax: 520-378-6553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberBH2414
License Number StateAZ

VIII. Authorized Official

Name: MR. BROOKE E BALCH
Title or Position: CFO
Credential:
Phone: 256-880-3339