Basic Information
| Provider Information | |||||||||
| NPI: | 1750335311 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEST YAVAPAI GUIDANCE CLINIC, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | POLARA HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3343 N. WINDSONG DR. | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863142283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284455211 | ||||||||
| FaxNumber: | 9287768484 | ||||||||
| Practice Location | |||||||||
| Address1: | 642 DAMERON DR | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863012411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284455211 | ||||||||
| FaxNumber: | 9287768484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 06/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | LANGLEY | ||||||||
| AuthorizedOfficialFirstName: | KARA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CAO | ||||||||
| AuthorizedOfficialTelephone: | 9284455211 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | BH309 | AZ | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 591562 | 05 | AZ | MEDICAID |