Basic Information
| Provider Information | |||||||||
| NPI: | 1386633915 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GILA RIVER HEALTH CARE CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AK-CHIN CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 38 | ||||||||
| Address2: | |||||||||
| City: | SACATON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851470038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025281200 | ||||||||
| FaxNumber: | 6025281255 | ||||||||
| Practice Location | |||||||||
| Address1: | 48203 W. FARRELL RD. | ||||||||
| Address2: | |||||||||
| City: | MARICOPA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851390038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205683881 | ||||||||
| FaxNumber: | 6025281255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2005 | ||||||||
| LastUpdateDate: | 05/31/2017 | ||||||||
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| AuthorizedOfficialLastName: | GEMBERLING | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6025281427 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NR1301X | AZ | Y | Hospitals | General Acute Care Hospital | Rural |
ID Information
| ID | Type | State | Issuer | Description | 334582 | 05 | AZ | MEDICAID |