Healthcare Provider Details

I. General information

NPI: 1679944789
Provider Name (Legal Business Name): PHOENIX RESIDENTIAL REENTRY AND COMMUNITY REINTEGRATION RESOURCE CENTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2015
Last Update Date: 10/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2274 E SAHUARO DR
PHOENIX AZ
85028-3117
US

IV. Provider business mailing address

2274 E SAHUARO DR
PHOENIX AZ
85028-3117
US

V. Phone/Fax

Practice location:
  • Phone: 602-736-7383
  • Fax:
Mailing address:
  • Phone: 602-736-7383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateAZ

VIII. Authorized Official

Name: BRENDA SANTOS
Title or Position: DIRECTOR
Credential: ACCOUNTANT
Phone: 602-697-1489