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General NPI Number Information
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NPI Number | 1790699502
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Entity Type | Organization
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Legal Business Name | COPPER CANYON RECOVERY GROUP
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Dates
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Enumeration Date | 09/29/2026
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Last Update Date | 09/29/2026
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Provider Practice Location Address
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Address Line | 201 W 4TH ST
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City | CASA GRANDE
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State | AZ
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Zip | 85122-4417
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Country | US
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Telephone | 520-251-0088
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Fax |
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Provider Business Mailing Address
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Address Line | 201 W 4TH ST
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City | CASA GRANDE
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State | AZ
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Zip | 85122-4417
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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 | CONSULTANT
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Name | TONY RENELLO
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Credential |
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Telephone | 480-606-8602
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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 | NULL
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