Provider Demographics
NPI:1982934618
Name:SEQUEL TSI OF AZ, LLC
Entity type:Organization
Organization Name:SEQUEL TSI OF AZ, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BANKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-335-2095
Mailing Address - Street 1:HIGHWAY 163
Mailing Address - Street 2:KAYENTA MOBILE HOME PARK #8
Mailing Address - City:KAYENTA
Mailing Address - State:AZ
Mailing Address - Zip Code:86033
Mailing Address - Country:US
Mailing Address - Phone:928-697-3154
Mailing Address - Fax:928-697-3156
Practice Address - Street 1:HIGHWAY 163
Practice Address - Street 2:KAYENTA MOBILE HOME PARK #8
Practice Address - City:KAYENTA
Practice Address - State:AZ
Practice Address - Zip Code:86033
Practice Address - Country:US
Practice Address - Phone:928-697-3154
Practice Address - Fax:928-697-3156
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SEQUELCARE OF AZ, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-31
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health