Organization
HACIENDA INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
PERRY PETRILLI (CEO)
(602) 243-4231
Entity
Organization
Contact information
Practice address
1402 E SOUTH MOUNTAIN AVE, PHOENIX, AZ 85042-7925
(602) 243-4231
(602) 323-5988
Mailing address
1402 E SOUTH MOUNTAIN AVE, PHOENIX, AZ 85042-7925
(602) 243-4231
(602) 323-5988
Taxonomy
Speciality
Code
Description
License number
State
315P00000X
Intellectual Disabilities Intermediate Care Facility
Primary
LTC0176
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
040064
—
AZ
05
—
ICF001
—
AZ
Enumeration date
05/02/2007
Last updated
02/13/2025
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