Healthcare Provider Details

I. General information

NPI: 1417747635
Provider Name (Legal Business Name): IBATL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2025
Last Update Date: 05/09/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 N IN BALANCE ROAD BUILDING 1&2
HUACHUCA CITY AZ
85616
US

IV. Provider business mailing address

6107 E GRANT RD
TUCSON AZ
85712-5828
US

V. Phone/Fax

Practice location:
  • Phone: 207-505-0143
  • Fax:
Mailing address:
  • Phone: 520-722-9631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY BARRASSO
Title or Position: COO
Credential:
Phone: 520-722-9631