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General NPI Number Information
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NPI Number | 1043574577
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Entity Type | Organization
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Legal Business Name | ARROWHEAD LODGE
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Dates
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Enumeration Date | 06/29/2012
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Last Update Date | 06/29/2012
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Provider Practice Location Address
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Address Line | 5113 W ARROWHEAD DR
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City | PRESCOTT
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State | AZ
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Zip | 86305-7304
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Country | US
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Telephone | 626-797-9977
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Fax |
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Provider Business Mailing Address
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Address Line | 5113 W ARROWHEAD DR
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City | PRESCOTT
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State | AZ
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Zip | 86305-7304
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | INSURANCE COORDINATOR
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Name | KENNETH ANTHONY GRAY
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Credential | LCSW
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Telephone | 626-797-9977
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | BH-3965
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License Number State | AZ
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