Basic Information
| Provider Information | |||||||||
| NPI: | 1649245135 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COBRE VALLEY REGIONAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SUPERIOR CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1134 W US HIGHWAY 60 | ||||||||
| Address2: | |||||||||
| City: | SUPERIOR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851733400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206892423 | ||||||||
| FaxNumber: | 5206895237 | ||||||||
| Practice Location | |||||||||
| Address1: | 1134 W US HIGHWAY 60 | ||||||||
| Address2: | |||||||||
| City: | SUPERIOR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206892423 | ||||||||
| FaxNumber: | 5206895237 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2006 | ||||||||
| LastUpdateDate: | 08/09/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JENSEN | ||||||||
| AuthorizedOfficialFirstName: | NEAL | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9284253261 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | H0126 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 934467 | 05 | AZ | MEDICAID | 1649245135 | 01 | AZ | NPI | OTHER |