Provider Demographics
NPI:1871085902
Name:OCOTILLO TREATMENT CENTER, LLC
Entity type:Organization
Organization Name:OCOTILLO TREATMENT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAICHA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MALDONADO
Authorized Official - Suffix:
Authorized Official - Credentials:MANAGER
Authorized Official - Phone:480-441-7700
Mailing Address - Street 1:3645 S ROME ST STE 204
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-7338
Mailing Address - Country:US
Mailing Address - Phone:480-771-4400
Mailing Address - Fax:
Practice Address - Street 1:3645 S ROME ST STE 204
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-7338
Practice Address - Country:US
Practice Address - Phone:480-771-4400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-04
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty