MEDICARE: DESERT EDGE MENTORING SERVICES

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	251S00000X	Community/Behavioral Health Agency	BH-3807	AZ

General Provider Information

NPI Number	:	1306021126
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESERT EDGE MENTORING SERVICES

Provider Business Mailing Address
First Line	:	PO BOX 1097
Second Line	:
City	:	LAVEEN
State	:	AZ
Zip	:	85339-1097
Country	:	US
Telephone Number	:	602-237-2485
Fax Number	:	602-274-6531

Provider Business Practice Location Address
First Line	:	1950 W HEATHERBRAE DR
Second Line	:	STE 10
City	:	PHOENIX
State	:	AZ
Zip	:	85015-5110
Country	:	US
Telephone Number	:	602-237-2485
Fax Number	:	602-274-6531

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. DENNIS GREGORY
Credential	:
Telephone Number	:	602-237-2485

Provider Enumeration Date	:	12/31/2007
Last Update Date	:	01/14/2011

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