Basic Information
Provider Information | |||||||||
NPI: | 1548210461 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNITED COMMUNITY HEALTH CENTER MARIA AUXILIADORA, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 81 W ESPERANZA BLVD | ||||||||
Address2: | STE 201 | ||||||||
City: | GREEN VALLEY | ||||||||
State: | AZ | ||||||||
PostalCode: | 856142667 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5206254401 | ||||||||
FaxNumber: | 5206258504 | ||||||||
Practice Location | |||||||||
Address1: | 275 W CONTINENTAL RD | ||||||||
Address2: | STE 141 | ||||||||
City: | GREEN VALLEY | ||||||||
State: | AZ | ||||||||
PostalCode: | 856142024 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5206253691 | ||||||||
FaxNumber: | 5205473994 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2006 | ||||||||
LastUpdateDate: | 07/15/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JIMENEZ | ||||||||
AuthorizedOfficialFirstName: | RODOLFO | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5204075600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | D.O. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | OTC-3915 | AZ | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.