1619148772 NPI number — WHITE MOUNTAIN APACHE

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 1619148772 NPI number — WHITE MOUNTAIN APACHE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WHITE MOUNTAIN APACHE
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:
1619148772
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1210
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:
85941-1210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-338-1808
Provider Business Mailing Address Fax Number:
928-338-5252

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
522 SOUTH FOURTH AVENUE
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:
928-338-1808
Provider Business Practice Location Address Fax Number:
928-338-5254
Provider Enumeration Date:
03/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CROMWELL
Authorized Official First Name:
EMMIE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
928-338-1808

Provider Taxonomy Codes

  • Taxonomy code: 343900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 044701 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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