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General NPI Number Information
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NPI Number | 1598433781
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Entity Type | Organization
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Legal Business Name | PINNACLE VISTA RESIDENTIAL LLC
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Dates
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Enumeration Date | 09/01/2021
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Last Update Date | 09/01/2021
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Provider Practice Location Address
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Address Line | 17510 W PINNACLE VISTA DR
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City | SURPRISE
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State | AZ
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Zip | 85387-1132
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Country | US
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Telephone | 480-677-5988
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Fax |
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Provider Business Mailing Address
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Address Line | 17510 W PINNACLE VISTA DR
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City | SURPRISE
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State | AZ
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Zip | 85387-1132
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Country | US
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Telephone | 480-334-1417
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | MONIQUE BLANTON
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Credential |
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Telephone | 480-334-1417
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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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