=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275971632
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARIZONA BEHAVIORAL CARE HOMES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2013
-----------------------------------------------------
Last Update Date | 12/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 560 N 159TH LN
-----------------------------------------------------
City | GOODYEAR
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85338-3276
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-904-2772
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4645 S LAKESHORE DR STE 3
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85282-7152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-840-1601
-----------------------------------------------------
Fax | 480-840-1613
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ROBERT CRAWFORD BREEDLOVE
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 480-840-1601
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | BH4271
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------