Healthcare Provider Details

I. General information

NPI: 1396204921
Provider Name (Legal Business Name): COMMUNITY MEDICAL SERVICES ARIZONA-PRIVATE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2019
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 SOUTH LAKE HAVASU AVENUE
LAKE HAVASU CITY AZ
86403-9368
US

IV. Provider business mailing address

8444 N 90TH ST STE 100
SCOTTSDALE AZ
85258-4437
US

V. Phone/Fax

Practice location:
  • Phone: 928-764-7266
  • Fax: 928-302-3615
Mailing address:
  • Phone: 602-248-8886
  • Fax: 602-248-8999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: NICK STAVROS
Title or Position: CEO
Credential:
Phone: 602-284-8886