Provider Demographics
NPI:1679757553
Name:CHICANOS POR LA CAUSA, INC.
Entity type:Organization
Organization Name:CHICANOS POR LA CAUSA, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:EDMUNDO
Authorized Official - Middle Name:
Authorized Official - Last Name:HIDALGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-257-0700
Mailing Address - Street 1:1112 E. BUCKEYE RD.
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85034
Mailing Address - Country:US
Mailing Address - Phone:602-257-0700
Mailing Address - Fax:602-307-9752
Practice Address - Street 1:4443 E. BROADWAY
Practice Address - Street 2:
Practice Address - City:CLAYPOOL
Practice Address - State:AZ
Practice Address - Zip Code:85532
Practice Address - Country:US
Practice Address - Phone:928-425-9244
Practice Address - Fax:928-425-9249
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHICANOS POR LA CAUSA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-27
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-2823251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health