1558483677 NPI number — TUBA CITY OUTPATIENT TREATMENT CENTER

Table of content: (NPI 1558483677)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558483677 NPI number — TUBA CITY OUTPATIENT TREATMENT CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TUBA CITY OUTPATIENT TREATMENT 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:
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:
1558483677
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1350
Provider Second Line Business Mailing Address:
BLDG. 25 MAIN STREET
Provider Business Mailing Address City Name:
TUBA CITY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86045-1350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-283-3346
Provider Business Mailing Address Fax Number:
928-283-3039

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MAIN STREET BLDG. 25
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUBA CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86045-1350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-283-3346
Provider Business Practice Location Address Fax Number:
928-283-3039
Provider Enumeration Date:
04/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DICKSON
Authorized Official First Name:
JANELL
Authorized Official Middle Name:
Authorized Official Title or Position:
BEHAVIORAL HEALTH DIRECTOR
Authorized Official Telephone Number:
928-657-8000

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 329492 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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