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General NPI Number Information
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NPI Number | 1437861259
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Entity Type | Organization
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Legal Business Name | SCOTTSDALE MODERN DETOX LLC
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Dates
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Enumeration Date | 12/23/2022
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Last Update Date | 12/28/2022
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Provider Practice Location Address
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Address Line | 7283 E EARLL DR BLDG B
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City | SCOTTSDALE
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State | AZ
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Zip | 85251-7230
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Country | US
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Telephone | 480-549-2220
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Fax |
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Provider Business Mailing Address
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Address Line | 7904 E CHAPARRAL RD STE A110-473
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City | SCOTTSDALE
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State | AZ
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Zip | 85250-7370
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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 | CEO
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Name | QUINN MCCULLOUGH
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Credential |
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Telephone | 480-466-8754
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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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Taxonomy #2
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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