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General NPI Number Information
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NPI Number | 1245908763
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Entity Type | Organization
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Legal Business Name | MOGOLLON TREATMENT CENTER
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Dates
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Enumeration Date | 08/31/2021
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Last Update Date | 11/01/2023
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Provider Practice Location Address
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Address Line | 306 W AERO DR
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City | PAYSON
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State | AZ
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Zip | 85541-5405
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Country | US
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Telephone | 714-910-4286
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Fax |
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Provider Business Mailing Address
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Address Line | 306 W AERO DR
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City | PAYSON
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State | AZ
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Zip | 85541-5405
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Country | US
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Telephone | 714-910-4286
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Fax |
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Authorized Official
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Title or Position | CHIEF OPERATIONS OFFICER
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Name | MR. TYRI NORMAN BLONDAL
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Credential |
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Telephone | 602-516-2414
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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