1477876639 NPI number — THE FORT DEFIANCE INDIAN HOSPITAL BOARD, INCORPORATION

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 1477876639 NPI number — THE FORT DEFIANCE INDIAN HOSPITAL BOARD, INCORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE FORT DEFIANCE INDIAN HOSPITAL BOARD, INCORPORATION
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:
FORT DEFIANCE INDIAN HOSPITAL
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:
1477876639
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 649
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT DEFIANCE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86504-0649
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-729-8000
Provider Business Mailing Address Fax Number:
928-729-3355

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CORNER OF ROUTE N12 & N7
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT DEFIANCE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-729-8000
Provider Business Practice Location Address Fax Number:
928-729-8169
Provider Enumeration Date:
03/02/2010

Additional Information

Authorized Official

Authorized Official Last Name:
WHITEHAIR
Authorized Official First Name:
ROBBIE
Authorized Official Middle Name:
Authorized Official Title or Position:
INTERIM CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
928-729-8902

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 523053 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: H0010 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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