Basic Information
Provider Information | |||||||||
NPI: | 1588115133 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DHHS PHS NAIHS CHINLE COMPREHENSIVE HEALTH CARE FACILITY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CHINLE COMPREHENSIVE HEALTH CARE FACILITY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | OFF HIGHWAY 191, HOSPITAL ROAD | ||||||||
Address2: |   | ||||||||
City: | CHINLE | ||||||||
State: | AZ | ||||||||
PostalCode: | 865038000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9286747030 | ||||||||
FaxNumber: | 9286747705 | ||||||||
Practice Location | |||||||||
Address1: | OFF HIGHWAY 191, HOSPITAL ROAD | ||||||||
Address2: |   | ||||||||
City: | CHINLE | ||||||||
State: | AZ | ||||||||
PostalCode: | 865038000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9286747030 | ||||||||
FaxNumber: | 9286747705 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/19/2016 | ||||||||
LastUpdateDate: | 10/19/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | YAZZIE | ||||||||
AuthorizedOfficialFirstName: | PATRICK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 9286747030 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 021171 | 05 | AZ |   | MEDICAID |