Basic Information
| Provider Information | |||||||||
| NPI: | 1114037496 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AJO COMMUNITY HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DESERT SENITA COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 N MALACATE ST | ||||||||
| Address2: | |||||||||
| City: | AJO | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853212254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203875651 | ||||||||
| FaxNumber: | 5203875347 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 N MALACATE ST | ||||||||
| Address2: | |||||||||
| City: | AJO | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853212254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203875651 | ||||||||
| FaxNumber: | 5203875347 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 01/07/2015 | ||||||||
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| AuthorizedOfficialLastName: | DRIVER | ||||||||
| AuthorizedOfficialFirstName: | FRAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5203875651 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | OTC-0274 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 155681 | 05 | AZ | MEDICAID | AZ0910930 | 01 | AZ | BCBS | OTHER |