1073755013 NPI number — GILA RIVER INDIAN COMMUNITY DEPARTMENT OF HUMAN SERVICES

Table of content: (NPI 1073755013)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073755013 NPI number — GILA RIVER INDIAN COMMUNITY DEPARTMENT OF HUMAN SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GILA RIVER INDIAN COMMUNITY DEPARTMENT OF HUMAN SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073755013
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 602
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAVEEN
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85339-0602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-796-3860
Provider Business Mailing Address Fax Number:
520-796-3801

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3850 N. 16 STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAVEEN
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-796-3860
Provider Business Practice Location Address Fax Number:
520-796-3801
Provider Enumeration Date:
04/06/2009

Additional Information

Authorized Official

Authorized Official Last Name:
CUMMINGS
Authorized Official First Name:
GLENN
Authorized Official Middle Name:
THOMAS
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
520-796-3802

Provider Taxonomy Codes

  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 074165 . This is a "ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 411673 . This is a "ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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