Healthcare Provider Details

I. General information

NPI: 1770676439
Provider Name (Legal Business Name): BRIGHTER HEIGHTS ARIZONA, LLC DBA HUALAPAI MOUNTAIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/05/2022
Certification Date: 07/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3240 HUALAPAI MOUNTAIN ROAD
KINGMAN AZ
86401
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: 928-753-2665
  • Fax: 928-753-1556
Mailing address:
  • Phone: 928-777-3280
  • Fax: 928-227-8493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberBH-3903
License Number StateAZ

VIII. Authorized Official

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