Basic Information
| Provider Information | |||||||||
| NPI: | 1700976222 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TERROS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TERROS HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3003 N CENTRAL AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026856000 | ||||||||
| FaxNumber: | 6023027925 | ||||||||
| Practice Location | |||||||||
| Address1: | 12835 N 32ND ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850326517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026856000 | ||||||||
| FaxNumber: | 6029926209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 11/06/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHASE | ||||||||
| AuthorizedOfficialFirstName: | PEGGY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 6026856000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TERROS, INC. | ||||||||
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| NPICertificationDate: | 11/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | OTC-6814 | AZ | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM0855X | OTC-6814 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 950934 | 05 | AZ | MEDICAID |