1033213053 NPI number — NORTHLAND CARES

Table of content: (NPI 1043485220)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033213053 NPI number — NORTHLAND CARES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHLAND CARES
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:
1033213053
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3112 CLEARWATER DR STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRESCOTT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86305-7187
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-776-4612
Provider Business Mailing Address Fax Number:
928-771-1767

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3112 CLEARWATER DR STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRESCOTT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86305-7187
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-776-4612
Provider Business Practice Location Address Fax Number:
928-771-1767
Provider Enumeration Date:
09/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARTINEZ
Authorized Official First Name:
JOHNNY
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
928-776-4612

Provider Taxonomy Codes

  • Taxonomy code: 251V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM2500X , with the licence number: 1033213053 , 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: 1598778177 . This is a "NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1033213053 . This is a "NATIONAL PROVIDER IDENTIFIER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 402329 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1356370571 . This is a "NATIONAL PROVIDER IDENTIFIER" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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