NPIMap

Organization Active NPI

Mogollon Treatment Center

  • Substance Abuse Rehabilitation Facility
  • Phoenix, AZ
National Provider Identifier
1639047020
Registry record updated Dec 12, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Substance Abuse Rehabilitation FacilityTaxonomy code 324500000X
Legal business name
MOGOLLON TREATMENT CENTER
Practice address
3338 W Kings Ave
Phoenix, AZ 85053-2940
Phone
(928) 466-4242
NPI assigned
Oct 27, 2025
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 12, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dustin Heracles Bullard
Title
Owner
Phone
(928) 466-4242

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Substance Abuse Rehabilitation Facility 324500000X Primary

Addresses

Primary practice location

3338 W Kings Ave
Phoenix, AZ 85053-2940

Mailing address

306 W Aero Dr
Payson, AZ 85541-5405
Phone (928) 466-4242

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
03D2334765Mogollon Treatment Center, LLC Dba3338 W Kings Ave, Phoenix, AZ 85053Certificate of waiverDec 1, 2027

National Provider Directory

National Provider Directory
Tax ID family
Mogollon Treatment Center6 organizations share this tax ID, including this one

Other organizations with this tax ID 5

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1761523200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1765497600000",
    "number": "1639047020",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "306 W AERO DR",
            "city": "PAYSON",
            "state": "AZ",
            "postal_code": "855415405",
            "telephone_number": "928-466-4242"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3338 W KINGS AVE",
            "city": "PHOENIX",
            "state": "AZ",
            "postal_code": "850532940",
            "telephone_number": "928-466-4242"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOGOLLON TREATMENT CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2025-10-27",
        "last_updated": "2025-12-12",
        "certification_date": "2025-12-12",
        "status": "A",
        "authorized_official_last_name": "BULLARD",
        "authorized_official_first_name": "DUSTIN",
        "authorized_official_middle_name": "HERACLES",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "928-466-4242"
    },
    "taxonomies": [
        {
            "code": "324500000X",
            "taxonomy_group": "",
            "desc": "Substance Abuse Rehabilitation Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Phoenix, AZ

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 12, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.