MEDICARE: MOUNTAINTOP BEHAVIORAL HEALTH SERVICES LLC

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	BH4024	AZ

General Provider Information

NPI Number	:	1194087031
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNTAINTOP BEHAVIORAL HEALTH SERVICES LLC

Provider Business Mailing Address
First Line	:	3838 W DUNBAR DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85041-6112
Country	:	US
Telephone Number	:	602-237-2820
Fax Number	:	888-843-7281

Provider Business Practice Location Address
First Line	:	3838 W DUNBAR DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85041-6112
Country	:	US
Telephone Number	:	602-237-2820
Fax Number	:	888-843-7281

Authorized Official
Title or Position	:	PROGRAM ADMINISTRATOR
Name	:	OLUGBENGA A TEPEDE
Credential	:	MBA
Telephone Number	:	623-363-6408

Provider Enumeration Date	:	06/15/2012
Last Update Date	:	06/15/2012

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