Healthcare Provider Details

I. General information

NPI: 1467654814
Provider Name (Legal Business Name): MINGUS MOUNTAIN ESTATE RESIDENCIAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HC 76 HWY 89 A N JUNCTION 151
PRESCOTT VALLEY AZ
86312-6485
US

IV. Provider business mailing address

PO BOX 26485
PRESCOTT VALLEY AZ
86312-6485
US

V. Phone/Fax

Practice location:
  • Phone: 602-335-2000
  • Fax:
Mailing address:
  • Phone: 602-335-2000
  • Fax: 602-249-1311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License NumberBH-1487
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberBH-312
License Number StateAZ

VIII. Authorized Official

Name: CHRIS BANKEN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 602-335-2000