Provider Demographics
NPI:1699869172
Name:EPIDAURUS
Entity type:Organization
Organization Name:EPIDAURUS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROD
Authorized Official - Middle Name:G
Authorized Official - Last Name:MULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-749-7178
Mailing Address - Street 1:PO BOX 3043
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85702-3043
Mailing Address - Country:US
Mailing Address - Phone:520-622-6489
Mailing Address - Fax:520-622-6490
Practice Address - Street 1:609 GOLD AVENUE SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102
Practice Address - Country:US
Practice Address - Phone:505-246-9300
Practice Address - Fax:505-246-8905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
94284267667OtherDUN
NM02957142001OtherLADAC