=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720177348
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LA FRONTERA CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2006
-----------------------------------------------------
Last Update Date | 07/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10845 N THORNYDALE RD
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85742-8154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-579-8786
-----------------------------------------------------
Fax | 520-579-8794
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 504 W 29TH ST
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85713-3353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-884-9920
-----------------------------------------------------
Fax | 520-792-0654
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | MS. KATHY WELLS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 520-838-5501
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 323P00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Residential Treatment Facility
-----------------------------------------------------
License Number | BH-2168
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------