MEDICARE: MOGOLLON TREATMENT CENTER

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	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1639047020
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOGOLLON TREATMENT CENTER

Provider Business Mailing Address
First Line	:	306 W AERO DR
Second Line	:
City	:	PAYSON
State	:	AZ
Zip	:	85541-5405
Country	:	US
Telephone Number	:	928-466-4242
Fax Number	:

Provider Business Practice Location Address
First Line	:	3338 W KINGS AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85053-2940
Country	:	US
Telephone Number	:	928-466-4242
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DUSTIN HERACLES BULLARD
Credential	:
Telephone Number	:	928-466-4242

Provider Enumeration Date	:	10/27/2025
Last Update Date	:	12/12/2025

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