1700941507 NPI number — COUNTY OF GILA

Table of content: (NPI 1700941507)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700941507 NPI number — COUNTY OF GILA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTY OF GILA
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:
6
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:
1700941507
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5515 S APACHE AVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
GLOBE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85501-4428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-402-8811
Provider Business Mailing Address Fax Number:
928-425-0794

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5515 S APACHE AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
GLOBE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85501-4428
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-402-8811
Provider Business Practice Location Address Fax Number:
928-425-0794
Provider Enumeration Date:
12/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PASTOR
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CHAIRMAN, BOARD OF SUPERVISORS
Authorized Official Telephone Number:
928-402-8756

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X , with the licence number:  OTC 3426 , 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: 479718 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2046559 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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