Basic Information
| Provider Information | |||||||||
| NPI: | 1255501565 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WINSLOW INDIAN HEALTH CARE GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WINSLOW MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 400 | ||||||||
| Address2: | |||||||||
| City: | WINSLOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860470400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282894646 | ||||||||
| FaxNumber: | 9282896289 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 N WILLIAMSON AVE | ||||||||
| Address2: | |||||||||
| City: | WINSLOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860472735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282894691 | ||||||||
| FaxNumber: | 9282896289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2008 | ||||||||
| LastUpdateDate: | 10/10/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ARMAO | ||||||||
| AuthorizedOfficialFirstName: | FRANCIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OF MEDICAL STAFF | ||||||||
| AuthorizedOfficialTelephone: | 9282894646 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WINSLOW INDIAN HEALTH CARE CENTER, INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 728701 | 05 | AZ | MEDICAID | 758542 | 05 | AZ | MEDICAID | 728727 | 05 | AZ | MEDICAID | 758526 | 05 | AZ | MEDICAID | 728719 | 05 | AZ | MEDICAID | 739089 | 05 | AZ | MEDICAID | 758518 | 05 | AZ | MEDICAID |