Healthcare Provider Details

I. General information

NPI: 1053884452
Provider Name (Legal Business Name): MOUNTAIN CARE OF SNOWFLAKE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2019
Last Update Date: 01/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 E 1ST ST S
SNOWFLAKE AZ
85937-5336
US

IV. Provider business mailing address

417 N PEAR
SNOWFLAKE AZ
85937-5089
US

V. Phone/Fax

Practice location:
  • Phone: 928-536-2726
  • Fax:
Mailing address:
  • Phone: 928-243-6623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: BRANDON D JOHNSON
Title or Position: DIRECTOR
Credential:
Phone: 928-243-6623