Basic Information
| Provider Information | |||||||||
| NPI: | 1407247547 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LA FRONTERA CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MENNINGER HOUSE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 504 W 29TH ST | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857133353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208385600 | ||||||||
| FaxNumber: | 5207920654 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 W NAVAJO RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857053514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204713822 | ||||||||
| FaxNumber: | 5208873476 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2015 | ||||||||
| LastUpdateDate: | 02/11/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RANIERI | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 5208385600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | BH4560 | AZ | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | BH4560 | 01 | AZ | BH LICENSE | OTHER |