MEDICARE: OZAREE PLACE 1

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	BH3418	AZ
2	101Y00000X	Counselor	BH3418	AZ

General Provider Information

NPI Number	:	1194050278
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OZAREE PLACE 1

Provider Business Mailing Address
First Line	:	7409 S 26TH LN
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85041-6477
Country	:	US
Telephone Number	:	602-237-5584
Fax Number	:	602-323-5021

Provider Business Practice Location Address
First Line	:	7409 S 26TH LN
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85041-6477
Country	:	US
Telephone Number	:	602-237-5584
Fax Number	:	602-323-5021

Authorized Official
Title or Position	:	OWNER/PROGRAM DIRECTOR
Name	:	MR. FREDERICK ORLANDER JACOBS
Credential	:
Telephone Number	:	602-469-0802

Provider Enumeration Date	:	10/07/2009
Last Update Date	:	10/07/2009

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Directions to “OZAREE PLACE 1 ” Practice Location

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