Provider Demographics
NPI:1316263643
Name:CATHOLIC COMMUNITY SERVICES OF SOUTHERN ARIZONA
Entity type:Organization
Organization Name:CATHOLIC COMMUNITY SERVICES OF SOUTHERN ARIZONA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOGOSOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-770-8517
Mailing Address - Street 1:5138 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-1309
Mailing Address - Country:US
Mailing Address - Phone:520-770-8517
Mailing Address - Fax:520-770-8517
Practice Address - Street 1:140 W SPEEDWAY BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-7686
Practice Address - Country:US
Practice Address - Phone:520-623-0344
Practice Address - Fax:520-770-8578
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CATHOLIC COMMUNITY SERVICES OF SOUTHERN ARIZONA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-12
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH914311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ588973OtherAHCCS