Basic Information
| Provider Information | |||||||||
| NPI: | 1891192126 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROBBELOTH | ||||||||
| FirstName: | JONATHAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1161 N EL DORADO PL STE 103 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857154607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207487108 | ||||||||
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| Practice Location | |||||||||
| Address1: | 503 E STERLING CANYON DR | ||||||||
| Address2: | |||||||||
| City: | VAIL | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856412289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203049422 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2014 | ||||||||
| LastUpdateDate: | 08/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 385HR2055X | 6173528 | AZ | N | Respite Care Facility | Respite Care | Respite Care, Mental Illness, Child | 253J00000X | Y | Agencies | Foster Care Agency |
ID Information
| ID | Type | State | Issuer | Description | 972921 | 05 | AZ | MEDICAID |