MEDICARE: TALAS HARBOR AT BUCKEYE, 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	283Q00000X	Psychiatric Hospital

General Provider Information

NPI Number	:	1992342265
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TALAS HARBOR AT BUCKEYE, LLC

Provider Business Mailing Address
First Line	:	1407 S 9TH AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85007-3904
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1407 S 9TH AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85007-3904
Country	:	US
Telephone Number	:	928-299-5178
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	RON STEWART
Credential	:
Telephone Number	:	253-241-4992

Provider Enumeration Date	:	12/05/2019
Last Update Date	:	02/22/2022

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