MEDICARE: AZ INTERACT 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	320800000X	Mental Illness Community Based Residential Treatment Facility	BH4514	AZ

General Provider Information

NPI Number	:	1760885347
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AZ INTERACT LLC

Provider Business Mailing Address
First Line	:	2325 W DESPERADO WAY
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85085-5777
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2325 W DESPERADO WAY
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85085-5777
Country	:	US
Telephone Number	:	602-696-0488
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	EDUARDO SANTANA
Credential	:
Telephone Number	:	602-636-0488

Provider Enumeration Date	:	09/26/2014
Last Update Date	:	09/26/2014

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