Basic Information
| Provider Information | |||||||||
| NPI: | 1114301157 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARANA HEALTH CARE, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 188 | ||||||||
| Address2: | |||||||||
| City: | MARANA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856530188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206824111 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8181 E IRVINGTON RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857094001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205741551 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2015 | ||||||||
| LastUpdateDate: | 07/18/2015 | ||||||||
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| AuthorizedOfficialLastName: | MEDINA | ||||||||
| AuthorizedOfficialFirstName: | DINNORAH | ||||||||
| AuthorizedOfficialMiddleName: | MILLAN | ||||||||
| AuthorizedOfficialTitleorPosition: | FAMILY NURSE PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 5202567534 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | NP-C | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | RN131609 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 329529 | 05 | AZ | MEDICAID |