Provider Demographics
NPI:1962896738
Name:SAGUARO FOUNDATION COMMUNITY LIVING PROGRAMS
Entity type:Organization
Organization Name:SAGUARO FOUNDATION COMMUNITY LIVING PROGRAMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:KERRY
Authorized Official - Last Name:VAN GUILDER
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:928-783-6069
Mailing Address - Street 1:1495 S 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-4603
Mailing Address - Country:US
Mailing Address - Phone:928-783-6069
Mailing Address - Fax:928-782-0061
Practice Address - Street 1:2620 S 16TH DR
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7055
Practice Address - Country:US
Practice Address - Phone:928-344-1618
Practice Address - Fax:928-782-0061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-19
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4508320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness