Basic Information
| Provider Information | |||||||||
| NPI: | 1811098742 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LA FRONTERA CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 502 W. 29TH STREET | ||||||||
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| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857133353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208849920 | ||||||||
| FaxNumber: | 5207920654 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 N. CRAYCROFT | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5202963296 | ||||||||
| FaxNumber: | 5207519856 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WELLS | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 5208385501 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | BH-1143 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 108151 | 05 | AZ | MEDICAID |