Provider Demographics
NPI:1700262490
Name:THE RIVER SOURCE IOP
Entity type:Organization
Organization Name:THE RIVER SOURCE IOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIORAL HEALTH INSURANCE COORDIN
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:STENZ
Authorized Official - Suffix:
Authorized Official - Credentials:BHT
Authorized Official - Phone:450-241-0170
Mailing Address - Street 1:128 W PEPPER PL
Mailing Address - Street 2:SUITE 126 & 128
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-7317
Mailing Address - Country:US
Mailing Address - Phone:480-241-0170
Mailing Address - Fax:480-610-3823
Practice Address - Street 1:128 W PEPPER PL
Practice Address - Street 2:SUITE 126 & 128
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-7317
Practice Address - Country:US
Practice Address - Phone:480-241-0170
Practice Address - Fax:480-610-3823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility