Provider Demographics
NPI:1538346275
Name:SENDERO DE SONORA INC.
Entity type:Organization
Organization Name:SENDERO DE SONORA INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:WIESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-870-6618
Mailing Address - Street 1:4881 N CALLE BUJIA
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-6168
Mailing Address - Country:US
Mailing Address - Phone:520-870-6618
Mailing Address - Fax:
Practice Address - Street 1:2502 N DODGE BLVD
Practice Address - Street 2:SUITE 160
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-2671
Practice Address - Country:US
Practice Address - Phone:520-618-8901
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SONORA BEHAVIORAL HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBHH2327320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ827420-01Medicaid