Basic Information
| Provider Information | |||||||||
| NPI: | 1184814550 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HAVEN SENDERO DE SONORA, INC. | ||||||||
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| OtherOrganizationName: | SENDERO DE SONORA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2502 N DODGE BLVD | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857162671 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2502 N DODGE BLVD | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857162671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206188901 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2007 | ||||||||
| LastUpdateDate: | 07/31/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BARNES | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | PAGE | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6152509091 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 323P00000X | BH2869 | AZ | Y | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |
No ID Information.