MEDICARE: CHICANOS POR LA CAUSA, INC.

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	320800000X	Mental Illness Community Based Residential Treatment Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	BH-008	OTHER	AZ	STATE LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427615145
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICANOS POR LA CAUSA, INC.

Provider Business Mailing Address
First Line	:	1112 E BUCKEYE RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85034-4043
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3639 W LINCOLN ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85009-5516
Country	:	US
Telephone Number	:	602-233-9747
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE VICE PRESIDENT
Name	:	MR. PEDRO CONS
Credential	:
Telephone Number	:	602-257-0700

Provider Enumeration Date	:	05/29/2019
Last Update Date	:	05/29/2019

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