Basic Information
| Provider Information | |||||||||
| NPI: | 1245824747 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COBRE VALLEY REGIONAL MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5880 S HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | GLOBE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855019447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284253261 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 S TILBURY DR | ||||||||
| Address2: | |||||||||
| City: | KEARNY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851371218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203635573 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2021 | ||||||||
| LastUpdateDate: | 02/24/2021 | ||||||||
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| AuthorizedOfficialLastName: | JENSEN | ||||||||
| AuthorizedOfficialFirstName: | NEAL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9284021122 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 020644 | 05 | AZ | MEDICAID |