=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063850824
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOPE LIVES - VIVE LA ESPERANZA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2013
-----------------------------------------------------
Last Update Date | 02/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 145 LAKE HAVASU AVE N
-----------------------------------------------------
City | LAKE HAVASU CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86403-5616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-208-4010
-----------------------------------------------------
Fax | 602-388-1567
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1551 W VAN BUREN ST
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85007-2413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-208-4010
-----------------------------------------------------
Fax | 602-388-1567
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DEBRA KURKOSKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-208-4010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------