Organization
MAIN STREET DIAGNOSTIC LLC
Active
Other names
Mingus Center (Level 1 Sub Acute Agency)
Organization subpart
No
Provider details
NPI number
Authorized official
MARIA CARRILLO (FINANCE COORDINATOR)
(928) 639-4440
Entity
Organization
Contact information
Practice address
636 N MAIN ST, COTTONWOOD, AZ 86326-3725
(928) 639-4440
(928) 639-3924
Mailing address
636 N MAIN ST, COTTONWOOD, AZ 86326-3725
(928) 639-4440
(928) 639-3924
Taxonomy
Speciality
Code
Description
License number
State
283Q00000X
Psychiatric Hospital
Primary
BH-2492
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
100322
CENPATICO - ADULTS
AS
01
—
2215360
CIGNA PROV REG #
AZ
01
—
3955228
AETNA
AZ
01
—
404204
JCAHCO
AZ
05
—
887317
—
AZ
01
—
AZ0209640
BCBS PROV REG. #
AZ
01
—
BH-2492
ADHS LICENSE L1 SUB ACUTE
AZ
Enumeration date
10/20/2005
Last updated
08/22/2020
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