Basic Information
Provider Information | |||||||||
NPI: | 1699079269 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WINSLOW INDIAN HEALTH CARE CENTER, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WINSLOW INDIAN HEALTH CARE CENTER, INC PHYSICAL THERAPY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 400 | ||||||||
Address2: |   | ||||||||
City: | WINSLOW | ||||||||
State: | AZ | ||||||||
PostalCode: | 860470400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9282894646 | ||||||||
FaxNumber: | 9282896290 | ||||||||
Practice Location | |||||||||
Address1: | 1527 N PARK DR | ||||||||
Address2: |   | ||||||||
City: | WINSLOW | ||||||||
State: | AZ | ||||||||
PostalCode: | 860472517 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9282894646 | ||||||||
FaxNumber: | 9282896290 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/22/2010 | ||||||||
LastUpdateDate: | 10/10/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ARMAO | ||||||||
AuthorizedOfficialFirstName: | FRANCIS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 9282894646 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | WINSLOW INDIAN HEALTH CARE CENTER, INC | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP0904X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Public Health, Federal |
ID Information
ID | Type | State | Issuer | Description | 728701 | 05 | AZ |   | MEDICAID |