Healthcare Provider Details

I. General information

NPI: 1497534895
Provider Name (Legal Business Name): BUCKHORN RESIDENTIAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2023
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1945 W VAN BUREN ST STE 1
PHOENIX AZ
85009-3805
US

IV. Provider business mailing address

1945 W VAN BUREN ST STE 1
PHOENIX AZ
85009-3805
US

V. Phone/Fax

Practice location:
  • Phone: 480-293-4327
  • Fax:
Mailing address:
  • Phone: 480-293-4327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL JOHNSON
Title or Position: CEO
Credential:
Phone: 480-293-4327