Healthcare Provider Details

I. General information

NPI: 1447615042
Provider Name (Legal Business Name): COBROS III, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2015
Last Update Date: 09/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7336 E 28TH PL
TUCSON AZ
85710-5559
US

IV. Provider business mailing address

PO BOX 43908
TUCSON AZ
85733-3908
US

V. Phone/Fax

Practice location:
  • Phone: 520-615-2255
  • Fax:
Mailing address:
  • Phone: 520-615-2255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number405971
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number405971
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number405971
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: RICHARD COLONNA
Title or Position: BUSINESS MANAGER
Credential:
Phone: 520-615-2255