MEDICARE: INTERMOUNTAIN CENTERS FOR HUMAN DEVELOPMENT 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	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	BH1012	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	BH1618	OTHER	AZ	STATE LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518055953
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERMOUNTAIN CENTERS FOR HUMAN DEVELOPMENT INC.

Provider Business Mailing Address
First Line	:	PO BOX 86537
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85754-6537
Country	:	US
Telephone Number	:	520-721-1887
Fax Number	:	520-721-0069

Provider Business Practice Location Address
First Line	:	8571 E TANQUE VERDE RD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85749-8917
Country	:	US
Telephone Number	:	520-721-1887
Fax Number	:	520-760-2481

Authorized Official
Title or Position	:	PRESIDENT AND CEO
Name	:	ROSE MARY LOPEZ
Credential	:	MBA
Telephone Number	:	520-721-1887

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	10/09/2020

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