1093986499 NPI number — ST JOHNS CONCHO SENIOR CITIZENS ASSOC

Table of content: (NPI 1093986499)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093986499 NPI number — ST JOHNS CONCHO SENIOR CITIZENS ASSOC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST JOHNS CONCHO SENIOR CITIZENS ASSOC
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:
1093986499
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 887
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST JOHNS
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85936-0887
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-337-2144
Provider Business Mailing Address Fax Number:
928-337-2581

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
395 SOUTH FIRST WEST ST
Provider Second Line Business Practice Location Address:
ST JOHNS CONCHO SENIOR CITIZENS ASSOC
Provider Business Practice Location Address City Name:
ST JOHNS
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85936-0887
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-337-2144
Provider Business Practice Location Address Fax Number:
928-337-2581
Provider Enumeration Date:
03/13/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CLANTON
Authorized Official First Name:
BETTY
Authorized Official Middle Name:
JO
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
928-337-2144

Provider Taxonomy Codes

  • Taxonomy code: 251V00000X , with the licence number:  P0496 , 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: 351560 . This is a "AHCCCS" identifier . This identifiers is of the category "OTHER".




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