Basic Information
Provider Information | |||||||||
NPI: | 1023320751 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LA FRONTERA CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 504 W 29TH ST | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857133353 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5208385600 | ||||||||
FaxNumber: | 5207920654 | ||||||||
Practice Location | |||||||||
Address1: | 1141 W GRANT RD | ||||||||
Address2: | SUITE 100 | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857055354 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5202068600 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/10/2010 | ||||||||
LastUpdateDate: | 07/10/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WELLS | ||||||||
AuthorizedOfficialFirstName: | KATHY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT/COO | ||||||||
AuthorizedOfficialTelephone: | 5208385501 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | BH3612 | AZ | N |   | Agencies | Case Management |   | 251S00000X | BH3612 | AZ | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.