Provider Demographics
NPI:1407679897
Name:RHR E COVINA OPERATOR LLC
Entity type:Organization
Organization Name:RHR E COVINA OPERATOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERSON
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-616-0266
Mailing Address - Street 1:11354 E COVINA ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-1713
Mailing Address - Country:US
Mailing Address - Phone:602-616-0266
Mailing Address - Fax:
Practice Address - Street 1:11354 E COVINA ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-1713
Practice Address - Country:US
Practice Address - Phone:602-616-0266
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH10304OtherARIZONA DEPARTMENT OF HEALTH SERVICES
AZ03D2310944OtherCLIA