Organization
BACK TO LIFE, INCORPORATED
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. GRACIE PADILLA CONTRERAS (CHIEF EXECUTIVE OFFICER)
(623) 594-4870
Entity
Organization
Contact information
Practice address
5915 W ROANOKE AVE, PHOENIX, AZ 85035-1639
(623) 594-4870
(623) 444-9213
Mailing address
PO BOX 8237, PHOENIX, AZ 85066-8237
(623) 594-4870
(623) 444-9213
Taxonomy
Speciality
Code
Description
License number
State
322D00000X
Emotionally Disturbed Childrens' Residential Treatment Facility
Primary
BH2772
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
143580
—
AZ
Enumeration date
11/28/2007
Last updated
11/29/2007
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