Basic Information
| Provider Information | |||||||||
| NPI: | 1316463276 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REHABILITATION HOSPITAL OF NORTHERN ARIZONA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 E RIVER PARK PLACE E #460 | ||||||||
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| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937201560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5598922500 | ||||||||
| FaxNumber: | 5598922442 | ||||||||
| Practice Location | |||||||||
| Address1: | 1851 N GEMINI DR | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860011607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287747070 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | THOMAS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7175915700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283X00000X | Y | Hospitals | Rehabilitation Hospital |
ID Information
| ID | Type | State | Issuer | Description | SH8743 | 01 | AZ | ARIZONA DEPT OF HEALTH SERVICES | OTHER | 393089 | 05 | AZ | MEDICAID | 616459 | 01 | THE JOINT COMMISION | OTHER |