Healthcare Provider Details

I. General information

NPI: 1497833644
Provider Name (Legal Business Name): ANASAZI FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 11/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1424 S STAPLEY DR
MESA AZ
85204-5877
US

IV. Provider business mailing address

1424 S STAPLEY DR
MESA AZ
85204-5877
US

V. Phone/Fax

Practice location:
  • Phone: 800-678-3445
  • Fax:
Mailing address:
  • Phone: 800-678-3445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License NumberBH1130
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberBH1130
License Number StateAZ

VIII. Authorized Official

Name: MR. MICHAEL MERCHANT
Title or Position: CEO PRESIDENT
Credential:
Phone: 480-892-7403