=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770955338
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHERN ARIZONA CENTER FOR ADDICTION, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2015
-----------------------------------------------------
Last Update Date | 03/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 195 PLAZA DR
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86303-5549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-499-5687
-----------------------------------------------------
Fax | 928-778-1089
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3195 STILLWATER DR STE A
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86305-7171
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-642-3030
-----------------------------------------------------
Fax | 928-778-1089
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACCOUNT MANAGER
-----------------------------------------------------
Name | ERIC MARINELLI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 928-642-3030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | OTC 7348
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------