1255700100 NPI number — MARANA HEALTH CENTER, INC

Table of content: (NPI 1255700100)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255700100 NPI number — MARANA HEALTH CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARANA HEALTH CENTER, INC
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:
WILMOT FAMILY HEALTH CENTER BH
Provider Other Organization Name Type Code:
3
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:
1255700100
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 188
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARANA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85653-0188
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-290-1100
Provider Business Mailing Address Fax Number:
520-290-8997

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
899 N WILMOT RD STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85711-1712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-290-1100
Provider Business Practice Location Address Fax Number:
520-290-8997
Provider Enumeration Date:
09/22/2015

Additional Information

Authorized Official

Authorized Official Last Name:
CARZOLI
Authorized Official First Name:
JOSHUA
Authorized Official Middle Name:
B
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
520-682-4111

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  OTC5399 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 914089 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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