1366774044 NPI number — NORTH COUNTRY HEALTHCARE INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366774044 NPI number — NORTH COUNTRY HEALTHCARE INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH COUNTRY HEALTHCARE 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:
GRAND CANYON URGENT CARE
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:
1366774044
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3630
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLAGSTAFF
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86003-3630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-213-6121
Provider Business Mailing Address Fax Number:
928-774-6687

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 CLINIC ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND CANYON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86023
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-638-2551
Provider Business Practice Location Address Fax Number:
928-638-2287
Provider Enumeration Date:
02/05/2010

Additional Information

Authorized Official

Authorized Official Last Name:
ROGGENBUCK
Authorized Official First Name:
ANN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
928-774-8325

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X , 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: OTC3823 . This is a "ARIZONA DEPARTMENT OF HEALTH SERVICES" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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