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General NPI Number Information
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NPI Number | 1497102495
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Entity Type | Organization
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Legal Business Name | HALLMARK BEHAVIORAL HEALTH @ LAGO, LLC
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Dates
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Enumeration Date | 05/19/2016
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Last Update Date | 02/06/2019
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Provider Practice Location Address
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Address Line | 688 S LAGO DR
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City | APACHE JUNCTION
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State | AZ
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Zip | 85120-5123
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Country | US
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Telephone | 480-625-1005
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Fax |
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Provider Business Mailing Address
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Address Line | 1550 E MCKELLIPS RD STE 109
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City | MESA
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State | AZ
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Zip | 85203-2753
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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 | MANGAGER
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Name | JEFF TILLEY
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Credential |
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Telephone | 602-695-4156
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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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 | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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