Basic Information
| Provider Information | |||||||||
| NPI: | 1346869039 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTCARE ARIZONA I, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | HILDY'S HOUSE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 94738 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891934738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023852090 | ||||||||
| FaxNumber: | 7029242575 | ||||||||
| Practice Location | |||||||||
| Address1: | 1160 AGATE RD | ||||||||
| Address2: | |||||||||
| City: | BULLHEAD CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287631945 | ||||||||
| FaxNumber: | 9287638809 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2020 | ||||||||
| LastUpdateDate: | 01/14/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JENKINS | ||||||||
| AuthorizedOfficialFirstName: | SHAWN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATIONS OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7023852090 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.