Healthcare Provider Details

I. General information

NPI: 1043994452
Provider Name (Legal Business Name): PHOENIX RESIDENTIAL TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9312 W HAPPY VALLEY RD
PEORIA AZ
85383-1262
US

IV. Provider business mailing address

4527 N 16TH ST STE 200
PHOENIX AZ
85016-5354
US

V. Phone/Fax

Practice location:
  • Phone: 833-988-4025
  • Fax:
Mailing address:
  • Phone: 760-835-7562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CHRISTOPHER NEWMAN
Title or Position: COO
Credential:
Phone: 760-835-7562