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General NPI Number Information
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NPI Number | 1992211619
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Entity Type | Organization
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Legal Business Name | GRANITE MOUNTAIN BEHAVIORAL HEALTH CARE OF AZ, LLC
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Dates
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Enumeration Date | 12/18/2017
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Last Update Date | 12/18/2017
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Provider Practice Location Address
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Address Line | 8183 E FLORENTINE RD
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City | PRESCOTT VALLEY
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State | AZ
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Zip | 86314-8481
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Country | US
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Telephone | 602-565-2055
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Fax | 602-565-2055
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Provider Business Mailing Address
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Address Line | 2651 N INDUSTRIAL WAY STE B
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City | PRESCOTT VALLEY
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State | AZ
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Zip | 86314-3545
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Country | US
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Telephone | 602-565-2055
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Fax | 866-758-1208
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Authorized Official
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Title or Position | ACCOUNTANT
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Name | NICK HERB
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Credential |
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Telephone | 602-565-2055
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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 | AZ
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