1205189917 NPI number — TCRHCC MOBILE HEALTHCARE VAN SYSTEM

Table of content: (NPI 1205189917)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205189917 NPI number — TCRHCC MOBILE HEALTHCARE VAN SYSTEM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TCRHCC MOBILE HEALTHCARE VAN SYSTEM
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:
KAIBETO CHAPTER HOUSE
Provider Other Organization Name Type Code:
5
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:
1205189917
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 600
Provider Second Line Business Mailing Address:
BASE OF OPERATIONS: 167 NORTH MAIN STREET
Provider Business Mailing Address City Name:
TUBA CITY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86060-0600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-283-2781
Provider Business Mailing Address Fax Number:
928-283-2677

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 MI N OF JCT HWY 160 & HWY 98
Provider Second Line Business Practice Location Address:
KAIBETO CHAPTER HOUSE
Provider Business Practice Location Address City Name:
KAIBETO
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-283-2501
Provider Business Practice Location Address Fax Number:
928-283-2677
Provider Enumeration Date:
10/18/2012

Additional Information

Authorized Official

Authorized Official Last Name:
ENGELKEN
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
T
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
928-283-2501

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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