Provider Demographics
NPI:1407247547
Name:LA FRONTERA CENTER, INC.
Entity type:Organization
Organization Name:LA FRONTERA CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EVP/COO
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:GUZMAN
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-838-5501
Mailing Address - Street 1:504 W 29TH ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85713-3353
Mailing Address - Country:US
Mailing Address - Phone:520-838-5600
Mailing Address - Fax:520-792-0654
Practice Address - Street 1:240 W NAVAJO RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-3514
Practice Address - Country:US
Practice Address - Phone:520-471-3822
Practice Address - Fax:520-887-3476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-11
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4560320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH4560OtherBH LICENSE
AZ987602Medicaid