Healthcare Provider Details

I. General information

NPI: 1962896738
Provider Name (Legal Business Name): SAGUARO FOUNDATION COMMUNITY LIVING PROGRAMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2015
Last Update Date: 04/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 S 16TH DR
YUMA AZ
85364-7055
US

IV. Provider business mailing address

1495 S 4TH AVE
YUMA AZ
85364-4603
US

V. Phone/Fax

Practice location:
  • Phone: 928-344-1618
  • Fax: 928-782-0061
Mailing address:
  • Phone: 928-783-6069
  • Fax: 928-782-0061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberBH4508
License Number StateAZ

VIII. Authorized Official

Name: MR. MICHAEL KERRY VAN GUILDER
Title or Position: EXECUTIVE DIRECTOR
Credential: M.S.
Phone: 928-783-6069