Provider Demographics
NPI:1124454236
Name:ARROWHEAD LODGE, LLC
Entity type:Organization
Organization Name:ARROWHEAD LODGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANCE
Authorized Official - Suffix:
Authorized Official - Credentials:DDIV
Authorized Official - Phone:928-227-2448
Mailing Address - Street 1:PO BOX 10835
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0835
Mailing Address - Country:US
Mailing Address - Phone:928-227-2448
Mailing Address - Fax:928-441-1516
Practice Address - Street 1:5113 W ARROWHEAD DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-7304
Practice Address - Country:US
Practice Address - Phone:928-227-2448
Practice Address - Fax:928-441-1516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-20
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-3965324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility