Basic Information
| Provider Information | |||||||||
| NPI: | 1528214079 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GILA HEALTH RESOURCES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 218 | ||||||||
| Address2: | |||||||||
| City: | MORENCI | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855400218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9288659184 | ||||||||
| FaxNumber: | 9288657571 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 BURRO ALY | ||||||||
| Address2: | |||||||||
| City: | MORENCI | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855409647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9288659184 | ||||||||
| FaxNumber: | 9288657571 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2008 | ||||||||
| LastUpdateDate: | 08/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | FARRINGTON | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | FINANCIAL MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9288657505 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GILA HEALTH RESOURCES | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | OTC3507 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 843088 | 05 | AZ | MEDICAID |