Basic Information
| Provider Information | |||||||||
| NPI: | 1366851842 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WHITERIVER SERVICE UNIT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 860 | ||||||||
| Address2: | |||||||||
| City: | WHITERIVER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283384911 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 WEST HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | WHITERIVER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283384911 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2014 | ||||||||
| LastUpdateDate: | 11/02/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 06/11/2015 | ||||||||
| NPIReactivationDate: | 09/12/2016 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SAMS | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
| AuthorizedOfficialMiddleName: | LOUISE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIETITIAN | ||||||||
| AuthorizedOfficialTelephone: | 9283383664 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | R.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 284300000X | 86008901 | OK | Y | Hospitals | Special Hospital |
No ID Information.