Basic Information
| Provider Information | |||||||||
| NPI: | 1336654383 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NATIVE HEALTH | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NATIVE AMERICAN COMMUNITY HEALTH CENTER, INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4041 N CENTRAL AVE BLDG C | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850123313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022795262 | ||||||||
| FaxNumber: | 6022795390 | ||||||||
| Practice Location | |||||||||
| Address1: | 777 W SOUTHERN AVE | ||||||||
| Address2: | BLDG E, STE 501 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852105062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805504048 | ||||||||
| FaxNumber: | 4802645099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2017 | ||||||||
| LastUpdateDate: | 07/31/2019 | ||||||||
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| AuthorizedOfficialLastName: | MURILLO | ||||||||
| AuthorizedOfficialFirstName: | WALTER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6022795262 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NATIVE HEALTH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 527706 | 05 | AZ | MEDICAID |