Provider Demographics
NPI:1427502947
Name:AZ INTERACT LLC
Entity type:Organization
Organization Name:AZ INTERACT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:EDUARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-487-8806
Mailing Address - Street 1:2325 W DESPERADO WAY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-5777
Mailing Address - Country:US
Mailing Address - Phone:602-487-8806
Mailing Address - Fax:
Practice Address - Street 1:6055 WEST CARIBE LANE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306
Practice Address - Country:US
Practice Address - Phone:602-487-8806
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4514320600000X
AZBH4802320600000X
AZBH4801320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1154781037Medicaid
AZ1760885347Medicaid
AZ1518327493Medicaid