Provider Demographics
NPI:1588380117
Name:GUARDIANS OF THE FOUR CORNERS LLC
Entity type:Organization
Organization Name:GUARDIANS OF THE FOUR CORNERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:DERY
Authorized Official - Suffix:
Authorized Official - Credentials:PHMNP-BC
Authorized Official - Phone:480-220-5864
Mailing Address - Street 1:109 S NEELY ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-5830
Mailing Address - Country:US
Mailing Address - Phone:480-220-5864
Mailing Address - Fax:
Practice Address - Street 1:38039 N DENA DR
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85140-4426
Practice Address - Country:US
Practice Address - Phone:480-220-5864
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-14
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility