Basic Information
Provider Information | |||||||||
NPI: | 1508207960 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ARIZONA CITY HEALTH ASSOCIATES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ELOY CITY HEALTH ASSOCIATES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1775 | ||||||||
Address2: |   | ||||||||
City: | ARIZONA CITY | ||||||||
State: | AZ | ||||||||
PostalCode: | 851231290 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5204665774 | ||||||||
FaxNumber: | 5203507859 | ||||||||
Practice Location | |||||||||
Address1: | 103 E 6TH ST | ||||||||
Address2: |   | ||||||||
City: | ELOY | ||||||||
State: | AZ | ||||||||
PostalCode: | 851312055 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5204665774 | ||||||||
FaxNumber: | 5203507859 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/15/2013 | ||||||||
LastUpdateDate: | 07/15/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SANCHEZ | ||||||||
AuthorizedOfficialFirstName: | SAMUEL | ||||||||
AuthorizedOfficialMiddleName: | EFRAINS | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5204665774 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ARIZONA CITY HEALTH ASSOCIATES, INC. | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | D.O. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 005911 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 813868 | 05 | AZ |   | MEDICAID |