MEDICARE: CENTRO DE AMISTAD, INCORPORADO

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-3759	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1062007	OTHER	AZ	VO BILLING NUMBER
2	957409	OTHER	AZ	AHCCCS PROVIDER NO.
3	BH-2504	OTHER	AZ	AZ BH LICENSE NO.
4	600252357	OTHER	AZ	MAGELLAN MIS#
5	A004334	OTHER	AZ	MHS VENDOR NO.

General Provider Information

NPI Number	:	1467523183
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRO DE AMISTAD, INCORPORADO

Provider Business Mailing Address
First Line	:	8202 S AVENIDA DEL YAQUI
Second Line	:
City	:	GUADALUPE
State	:	AZ
Zip	:	85283-1024
Country	:	US
Telephone Number	:	480-839-2926
Fax Number	:	480-839-9985

Provider Business Practice Location Address
First Line	:	2923 N 33RD AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85017-5201
Country	:	US
Telephone Number	:	602-393-3840
Fax Number	:	602-393-3842

Authorized Official
Title or Position	:	PRESIDENT AND CEO
Name	:	RITA MONROY
Credential	:
Telephone Number	:	480-839-2926

Provider Enumeration Date	:	11/13/2006
Last Update Date	:	12/07/2010

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Directions to “CENTRO DE AMISTAD, INCORPORADO ” Practice Location

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