Basic Information
| Provider Information | |||||||||
| NPI: | 1104980911 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GILA RIVER HEALTH CARE CORPORATION DME | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DME DIVISION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 483 W. SEED FARM ROAD | ||||||||
| Address2: | P. O. BOX 38 | ||||||||
| City: | SACATON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8884848526 | ||||||||
| FaxNumber: | 6025281245 | ||||||||
| Practice Location | |||||||||
| Address1: | 483 WEST SEED FARM RD | ||||||||
| Address2: | GILA RIVER HEALTH CARE CORPORATION | ||||||||
| City: | SACATON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852470038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8884848526 | ||||||||
| FaxNumber: | 6025281245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ELLORY | ||||||||
| AuthorizedOfficialFirstName: | LOREN | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | C.E.O. | ||||||||
| AuthorizedOfficialTelephone: | 6025281431 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 07-488076N | AZ | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.