Basic Information
| Provider Information | |||||||||
| NPI: | 1053523357 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GILA RIVER HEALTH CARE CORPORATION | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | TRANSPORTATION DEPARTMENT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 38 | ||||||||
| Address2: | 483 W. SEED FARM RD. | ||||||||
| City: | SACATON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025625170 | ||||||||
| FaxNumber: | 6025281296 | ||||||||
| Practice Location | |||||||||
| Address1: | 483 W. SEED FARM RD | ||||||||
| Address2: | |||||||||
| City: | SACATON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205625170 | ||||||||
| FaxNumber: | 6025281296 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 6025281203 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 343900000X | NA | Y | Transportation Services | Non-emergency Medical Transport (VAN) |
ID Information
| ID | Type | State | Issuer | Description | 078042 | 05 | AZ | MEDICAID |