1710475124 NPI number — SAN CARLOS APACHE HEALTHCARE CORPORATION

Table of content: (NPI 1710475124)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710475124 NPI number — SAN CARLOS APACHE HEALTHCARE CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN CARLOS APACHE HEALTHCARE CORPORATION
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:
1710475124
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 787
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PERIDOT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85542-0787
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-475-1290
Provider Business Mailing Address Fax Number:
928-475-7371

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 MEDICINE WAY ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PERIDOT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-475-1400
Provider Business Practice Location Address Fax Number:
928-475-7371
Provider Enumeration Date:
05/01/2018

Additional Information

Authorized Official

Authorized Official Last Name:
CHEE
Authorized Official First Name:
VALERIE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
DIRECTOR PATIENT FINANCIAL SERVICES
Authorized Official Telephone Number:
928-475-1290

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 059898 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 099458 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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