Healthcare Provider Details

I. General information

NPI: 1437861259
Provider Name (Legal Business Name): SCOTTSDALE MODERN DETOX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2022
Last Update Date: 12/28/2022
Certification Date: 12/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7283 E EARLL DR BLDG B
SCOTTSDALE AZ
85251-7230
US

IV. Provider business mailing address

7904 E CHAPARRAL RD STE A110-473
SCOTTSDALE AZ
85250-7370
US

V. Phone/Fax

Practice location:
  • Phone: 480-549-2220
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: QUINN MCCULLOUGH
Title or Position: CEO
Credential:
Phone: 480-466-8754