Provider Demographics
NPI:1417391293
Name:PRESCOTT DETOX CENTER, LLC
Entity type:Organization
Organization Name:PRESCOTT DETOX CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:ASHBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-991-0280
Mailing Address - Street 1:831 GAIL GARDNER WAY
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-1606
Mailing Address - Country:US
Mailing Address - Phone:928-445-3834
Mailing Address - Fax:928-445-3649
Practice Address - Street 1:831 GAIL GARDNER WAY
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1606
Practice Address - Country:US
Practice Address - Phone:928-445-3834
Practice Address - Fax:928-445-3649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-23
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4207276400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit