Basic Information
| Provider Information | |||||||||
| NPI: | 1013213404 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARIPOSA COMMUNITY HEALTH CENTER | ||||||||
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| OtherOrganizationName: | MCHC RIO RICO | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 825 N GRAND AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | NOGALES | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856212385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207612128 | ||||||||
| FaxNumber: | 5202811112 | ||||||||
| Practice Location | |||||||||
| Address1: | 1103 CIRCULO MERCADO | ||||||||
| Address2: | |||||||||
| City: | RIO RICO | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856486248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5202811550 | ||||||||
| FaxNumber: | 5202814487 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2011 | ||||||||
| LastUpdateDate: | 07/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | SICURELLO | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5207612128 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223D0001X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Dental Public Health | 1223X0400X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics | 163W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | 164W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Licensed Practical Nurse | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 03-1885 | 01 | AZ | MEDICARE PART A GROUP # | OTHER | ZFQ03-1885 | 01 | AZ | MEDICARE PART B GROUP # | OTHER |