Healthcare Provider Details

I. General information

NPI: 1578482402
Provider Name (Legal Business Name): MOGOLLON TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9417 N 17TH PL
PHOENIX AZ
85020-2310
US

IV. Provider business mailing address

306 W AERO DR
PAYSON AZ
85541-5405
US

V. Phone/Fax

Practice location:
  • Phone: 928-466-4242
  • Fax: 928-474-7460
Mailing address:
  • Phone: 928-466-4242
  • Fax: 928-474-7460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: DUSTIN HERACLES BULLARD
Title or Position: OWNER
Credential:
Phone: 928-466-4242