Healthcare Provider Details

I. General information

NPI: 1639047020
Provider Name (Legal Business Name): MOGOLLON TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2025
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3338 W KINGS AVE
PHOENIX AZ
85053-2940
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:
Mailing address:
  • Phone: 928-466-4242
  • Fax:

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