1992967780 NPI number — COBRE VALLEY REGIONAL MEDICAL CENTER

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 1992967780 NPI number — COBRE VALLEY REGIONAL MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COBRE VALLEY REGIONAL MEDICAL CENTER
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:
KEARNY CLINIC
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:
1992967780
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 519
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KEARNY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85237-0519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-363-5573
Provider Business Mailing Address Fax Number:
520-363-5611

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 S TILBURY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KEARNY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-363-5573
Provider Business Practice Location Address Fax Number:
520-363-5611
Provider Enumeration Date:
07/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
STAPLETON
Authorized Official First Name:
FRANK
Authorized Official Middle Name:
A
Authorized Official Title or Position:
REGIONAL CLINICS DIRECTOR
Authorized Official Telephone Number:
928-402-1131

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  H0126 , 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: 1992967780 . This is a "NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 934437 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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