Provider Demographics
NPI:1487367314
Name:THE RIVER SOURCE TREATMENT CENTER CASA GRANDE, LLC
Entity type:Organization
Organization Name:THE RIVER SOURCE TREATMENT CENTER CASA GRANDE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-582-4718
Mailing Address - Street 1:PO BOX 4293
Mailing Address - Street 2:
Mailing Address - City:ARIZONA CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85123-2669
Mailing Address - Country:US
Mailing Address - Phone:480-298-7301
Mailing Address - Fax:520-413-5944
Practice Address - Street 1:16286 S. SUNLAND GIN RD
Practice Address - Street 2:STE B
Practice Address - City:ARIZONA CITY
Practice Address - State:AZ
Practice Address - Zip Code:85123-8512
Practice Address - Country:US
Practice Address - Phone:866-367-8069
Practice Address - Fax:520-413-5944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ544985Medicaid