Provider Demographics
NPI:1427154368
Name:NEW CASA DE AMIGAS
Entity type:Organization
Organization Name:NEW CASA DE AMIGAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:LYLE
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-265-9987
Mailing Address - Street 1:1648 W COLTER ST # 8
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-3022
Mailing Address - Country:US
Mailing Address - Phone:602-265-9987
Mailing Address - Fax:602-265-9983
Practice Address - Street 1:1648 W COLTER ST # 8
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-3022
Practice Address - Country:US
Practice Address - Phone:602-265-9987
Practice Address - Fax:602-265-9983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH 1611324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility