1366851842 NPI number — WHITERIVER SERVICE UNIT

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 1366851842 NPI number — WHITERIVER SERVICE UNIT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WHITERIVER SERVICE UNIT
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:
1366851842
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
06/11/2015
NPI Reactivation Date:
09/12/2016

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 860
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITERIVER
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85941
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-338-4911
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 WEST HOSPITAL DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITERIVER
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85941
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-338-4911
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/08/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SAMS
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
LOUISE
Authorized Official Title or Position:
DIETITIAN
Authorized Official Telephone Number:
928-338-3664

Provider Taxonomy Codes

  • Taxonomy code: 284300000X , with the licence number:  86008901 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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