1366993636 NPI number — FORT DEFIANCE INDIAN HOSPITAL BOARD, INC

Table of content: (NPI 1366993636)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366993636 NPI number — FORT DEFIANCE INDIAN HOSPITAL BOARD, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FORT DEFIANCE INDIAN HOSPITAL BOARD, INC
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:
1366993636
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 589
Provider Second Line Business Mailing Address:
FORT DEFIANCE INDIAN HOSPITAL BOARD, INC.
Provider Business Mailing Address City Name:
FORT DEFIANCE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-279-8000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CORNER OF ROUTE N12 AND N7
Provider Second Line Business Practice Location Address:
FORT DEFIANCE INDIAN HOSPITAL BOARD, INC
Provider Business Practice Location Address City Name:
FORT DEFIANCE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86504-0589
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-279-8000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/20/2016

Additional Information

Authorized Official

Authorized Official Last Name:
ARINTINO
Authorized Official First Name:
SANDI
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
928-729-8902

Provider Taxonomy Codes

  • Taxonomy code: 282NR1301X , with the licence number:  MD2012-0766 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1982915443 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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