Organization
CACTUS SAGE LLC
Active
Other names
Cactus Sage 3
Organization subpart
No
Provider details
NPI number
Authorized official
GERALDINE MUTWOL (CEO)
(623) 225-1240
Entity
Organization
Contact information
Practice address
6522 W LATONA RD, LAVEEN, AZ 85339-3083
(623) 225-1240
Mailing address
3848 E POLLACK ST, PHOENIX, AZ 85042-6207
(623) 225-1240
Taxonomy
Speciality
Code
Description
License number
State
320800000X
Mental Illness Community Based Residential Treatment Facility
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
BH7542
AZ DEPARTMENT OF HEALTH SERVICES
AZ
Enumeration date
04/12/2022
Last updated
04/12/2022
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