MEDICARE: SEDONA SKY OPCO LLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
2	323P00000X	Psychiatric Residential Treatment Facility

General Provider Information

NPI Number	:	1700505872
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEDONA SKY OPCO LLC

Provider Business Mailing Address
First Line	:	3090 E CORONADO TRL
Second Line	:
City	:	RIMROCK
State	:	AZ
Zip	:	86335-5283
Country	:	US
Telephone Number	:	312-485-5680
Fax Number	:	928-371-2345

Provider Business Practice Location Address
First Line	:	3090 E CORONADO TRL
Second Line	:
City	:	RIMROCK
State	:	AZ
Zip	:	86335-5283
Country	:	US
Telephone Number	:	928-567-1322
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	ERIN SMITH
Credential	:
Telephone Number	:	855-988-9111

Provider Enumeration Date	:	08/23/2022
Last Update Date	:	11/29/2024

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