=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962749499
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VISIONS OF HOPE ARIZIONA, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2013
-----------------------------------------------------
Last Update Date | 01/03/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6411 E THOMAS RD
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85251-6005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-994-4866
-----------------------------------------------------
Fax | 602-944-2141
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 707 E NORTHERN AVE
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85020-4154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-404-1555
-----------------------------------------------------
Fax | 602-944-2141
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INTERIM CEO
-----------------------------------------------------
Name | MR. FARON JACK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 602-404-1555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | BH4146
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------