Basic Information
| Provider Information | |||||||||
| NPI: | 1538346275 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SENDERO DE SONORA INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4881 N CALLE BUJIA | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857186168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208706618 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2502 N DODGE BLVD | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857162671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206188901 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2008 | ||||||||
| LastUpdateDate: | 01/24/2008 | ||||||||
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| AuthorizedOfficialLastName: | WIESE | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5208706618 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SONORA BEHAVIORAL HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | BHH2327 | AZ | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | 827420-01 | 05 | AZ | MEDICAID |