Basic Information
| Provider Information | |||||||||
| NPI: | 1245908763 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOGOLLON TREATMENT CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 306 W AERO DR | ||||||||
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| City: | PAYSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855415405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149104286 | ||||||||
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| Practice Location | |||||||||
| Address1: | 306 W AERO DR | ||||||||
| Address2: | |||||||||
| City: | PAYSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855415405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149104286 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2021 | ||||||||
| LastUpdateDate: | 08/31/2021 | ||||||||
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| AuthorizedOfficialLastName: | HURLEY | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
| AuthorizedOfficialMiddleName: | DIANE | ||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7149104286 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.