1841634201 NPI number — ICE HEALTH SERVICE CORPS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841634201 NPI number — ICE HEALTH SERVICE CORPS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ICE HEALTH SERVICE CORPS
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:
1841634201
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3250 N PINAL PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLORENCE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85132-9459
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-868-2049
Provider Business Mailing Address Fax Number:
520-868-1547

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3250 N PINAL PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLORENCE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85132-9459
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-868-2049
Provider Business Practice Location Address Fax Number:
520-868-1547
Provider Enumeration Date:
04/28/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
STEPHEN
Authorized Official First Name:
BRENT
Authorized Official Middle Name:
Authorized Official Title or Position:
HEALTH SERVICE ADMINISTRATOR
Authorized Official Telephone Number:
520-868-8439

Provider Taxonomy Codes

  • Taxonomy code: 261QP0904X , with the licence number:  0024169459 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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