Basic Information
| Provider Information | |||||||||
| NPI: | 1376000786 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDREN'S CLINICS FOR REHABILITATIVE SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 N WYATT DR | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857126106 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2600 N WYATT DR | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857126106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203245437 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2019 | ||||||||
| LastUpdateDate: | 02/22/2019 | ||||||||
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| AuthorizedOfficialLastName: | MCGUIRE | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 5203243027 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 170359 | 05 | AZ | MEDICAID |