MOGOLLON TREATMENT CENTER
NPI 1639047020
Substance Abuse Rehabilitation Facility in Phoenix, AZ
About Mogollon Treatment Center NPPES
Official registry information on file with the National Plan and Provider Enumeration System.
MOGOLLON TREATMENT CENTER (NPI 1639047020) is a healthcare organization registered as a substance abuse rehabilitation facility in Phoenix, Arizona and active in the NPI registry since October 2025. The organization holds a CLIA Waiver certificate valid through December 1, 2027 and lists Dustin Heracles Bullard, Owner, as its authorized official.
NPPES Registry Identity
Specialties & Licenses
CLIA Laboratory Certificates CMS CLIA
Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.
Certificate of Waiver 03D2334765
Mogollon Treatment Center, LLC Dba Mogollon Residential North Phoenix · Phoenix, AZOther Providers at the Same Location NPPES 2
Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.
PHOENIX, AZ 85053
PHOENIX, AZ 85053
Frequently Asked Questions NPPES & CMS
Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.
What is Mogollon Treatment Center's NPI number?
The NPI number for Mogollon Treatment Center is 1639047020. It was assigned to this organization in the NPPES registry on October 27, 2025.
Where is Mogollon Treatment Center located?
Mogollon Treatment Center is located at 3338 W Kings Ave, Phoenix, AZ 85053. The listed phone number is (928) 466-4242.
What is Mogollon Treatment Center's specialty?
The primary specialty registered for this NPI is Substance Abuse Rehabilitation Facility with taxonomy code 324500000X.
Does Mogollon Treatment Center hold a CLIA laboratory certificate?
Yes. A Certificate of Waiver (number 03D2334765) is associated with this NPI, valid through December 1, 2027. CLIA certificates authorize laboratory testing under the federal Clinical Laboratory Improvement Amendments program.
When was this NPI record last updated?
The NPPES record for Mogollon Treatment Center was last updated on December 12, 2025. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 8 months ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.
# Mogollon Treatment Center · NPI 1639047020
Substance Abuse Rehabilitation Facility organization in Phoenix, Arizona. Organization record, active in the CMS NPPES registry since October 27, 2025.
## Identity
- **NPI:** 1639047020 (Entity type: Organization)
- **Enumerated:** October 27, 2025
- **Primary specialty:** Substance Abuse Rehabilitation Facility · taxonomy 324500000X
- **Organization subpart:** No
- **Authorized official:** Dustin Bullard, OWNER
## Practice location
- **Address:** 3338 W KINGS AVE, Phoenix, AZ 85053-2940
- **Phone:** (928) 466-4242
## Record status
- **NPPES last updated:** December 12, 2025
- **CLIA laboratory certificates:** 1 on file
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Source: [NPI Profile](https://npiprofile.com/npi/1639047020) · Data from the CMS NPPES public registry.