Healthcare Provider Details

I. General information

NPI: 1043504376
Provider Name (Legal Business Name): COMMUNITY INTERVENTION ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2011
Last Update Date: 02/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 BLVD DEL REY DAVID
NOGALES AZ
85621
US

IV. Provider business mailing address

2851 S AVE B BLDG 4
YUMA AZ
85364-7726
US

V. Phone/Fax

Practice location:
  • Phone: 520-394-7400
  • Fax: 520-377-9596
Mailing address:
  • Phone: 928-376-0026
  • Fax: 928-782-2298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberB-3771
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberBH-3771
License Number StateAZ

VIII. Authorized Official

Name: MR. FRED R COGBURN
Title or Position: CEO
Credential:
Phone: 928-376-0026