1821386400 NPI number — GRAND CANYON STATE INPATIENT SERVICES

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 1821386400 NPI number — GRAND CANYON STATE INPATIENT SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND CANYON STATE INPATIENT SERVICES
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:
1821386400
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
815 S PALAFOX ST
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32502-5960
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-444-7009
Provider Business Mailing Address Fax Number:
800-305-3233

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2174 W OAK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOUGLAS
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85607-6003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-444-7009
Provider Business Practice Location Address Fax Number:
800-305-3233
Provider Enumeration Date:
07/15/2011

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
W
Authorized Official Title or Position:
EXEC. VP, EPP, GENERAL PARTNER
Authorized Official Telephone Number:
800-444-7009

Provider Taxonomy Codes

  • Taxonomy code: 208M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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