Basic Information
| Provider Information | |||||||||
| NPI: | 1497277651 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WHITE MOUNTAIN REGIONAL MEDICAL CENTER RURAL HEALTH CLINIC - ST. JOHNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118 S MOUNTAIN AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGERVILLE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859385104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283337333 | ||||||||
| FaxNumber: | 9283337157 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 EAST FIRST STREET SOUTH | ||||||||
| Address2: | |||||||||
| City: | ST. JOHNS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283337333 | ||||||||
| FaxNumber: | 9283337157 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2017 | ||||||||
| LastUpdateDate: | 05/06/2022 | ||||||||
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| AuthorizedOfficialLastName: | NELSON | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINIC MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9283337173 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WHITE MOUNTAIN COMMUNITIES HOSPITAL INC | ||||||||
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| AuthorizedOfficialCredential: | RN-BC | ||||||||
| NPICertificationDate: | 05/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | OTC7868 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.