1821582529 NPI number — CHIRICAHUA COMMUNITY HEALTH CENTERS, INC

Table of content: (NPI 1821582529)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821582529 NPI number — CHIRICAHUA COMMUNITY HEALTH CENTERS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHIRICAHUA COMMUNITY HEALTH CENTERS, 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:
1821582529
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1205 F AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOUGLAS
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85607-1920
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-364-6852
Provider Business Mailing Address Fax Number:
520-364-4261

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
335 SOUTH OCOTILLO AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-364-1429
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/18/2018

Additional Information

Authorized Official

Authorized Official Last Name:
MELK
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
P
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
520-364-1429

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , with the licence number:  OTC8971 , 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: 396154 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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