Basic Information
| Provider Information | |||||||||
| NPI: | 1164675930 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHOICES NETWORK OF ARIZONA, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3003 N CENTRAL AVE STE 305 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029523400 | ||||||||
| FaxNumber: | 6029523401 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 N 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850134108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022644331 | ||||||||
| FaxNumber: | 6022644095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2008 | ||||||||
| LastUpdateDate: | 01/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | MCKELVEY | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6029523400 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHOICES NETWORK OF ARIZONA, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 385224 | 05 | AZ | MEDICAID |