Basic Information
| Provider Information | |||||||||
| NPI: | 1538238621 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMPASS VIDA LIBRE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2475 N JACKRABBIT AVE | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857451208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208825608 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2950 N DODGE BLVD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857162012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206245272 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | O'NEILL | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | INTERIM CEO | ||||||||
| AuthorizedOfficialTelephone: | 5208825608 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 284300000X | Y | Hospitals | Special Hospital |
ID Information
| ID | Type | State | Issuer | Description | 592594 | 05 | AZ | MEDICAID |