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General NPI Number Information
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NPI Number | 1861070260
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Entity Type | Organization
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Legal Business Name | PERFORMANCE INTENSIVE OUTPATIENT, LLC
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Dates
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Enumeration Date | 03/30/2021
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Last Update Date | 06/26/2021
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Provider Practice Location Address
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Address Line | 9525 E DOUBLETREE RANCH RD STE 105
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City | SCOTTSDALE
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State | AZ
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Zip | 85258-5538
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Country | US
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Telephone | 480-588-3745
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Fax |
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Provider Business Mailing Address
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Address Line | 9525 E DOUBLETREE RANCH RD STE 105
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City | SCOTTSDALE
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State | AZ
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Zip | 85258-5538
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Country | US
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Telephone | 480-588-3745
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Fax | 480-809-6559
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Authorized Official
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Title or Position | MEMBER/CHIEF ADMINISTRATIVE OFFICER
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Name | BENJAMIN TYLER TERRUSA
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Credential |
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Telephone | 818-251-0123
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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