Basic Information
| Provider Information | |||||||||
| NPI: | 1013523539 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARIPOSA COMMUNITY HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MARIPOSA NOGALES WEST | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 825 N GRAND AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | NOGALES | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856211061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207612128 | ||||||||
| FaxNumber: | 5202811112 | ||||||||
| Practice Location | |||||||||
| Address1: | 1209 W TARGET RANGE RD | ||||||||
| Address2: | |||||||||
| City: | NOGALES | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856212466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5202874747 | ||||||||
| FaxNumber: | 5202811112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2020 | ||||||||
| 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 | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 091922 | 05 | AZ | MEDICAID |