Provider Demographics
NPI:1891048062
Name:SANCTUARY
Entity type:Organization
Organization Name:SANCTUARY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MILDRED
Authorized Official - Middle Name:Q
Authorized Official - Last Name:LUJAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:671-475-7101
Mailing Address - Street 1:406 MAIMAI ST
Mailing Address - Street 2:
Mailing Address - City:CHALAN PAGO
Mailing Address - State:GU
Mailing Address - Zip Code:96910-5669
Mailing Address - Country:US
Mailing Address - Phone:671-475-7101
Mailing Address - Fax:
Practice Address - Street 1:406 MAIMAI ST
Practice Address - Street 2:
Practice Address - City:CHALAN PAGO
Practice Address - State:GU
Practice Address - Zip Code:96910-5669
Practice Address - Country:US
Practice Address - Phone:671-475-7101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GU2696251B00000X, 251S00000X, 252Y00000X, 305S00000X, 324500000X, 322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency
No305S00000XManaged Care OrganizationsPoint of Service
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility