Basic Information
Provider Information | |||||||||
NPI: | 1700962131 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DHHS PHS NAIHS FORT DEFIANCE HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PHS FORT DEFIANCE INDIAN HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 649 | ||||||||
Address2: | CORNER OF ROUTE N12 & N7 | ||||||||
City: | FORT DEFIANCE | ||||||||
State: | AZ | ||||||||
PostalCode: | 865040649 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9287298000 | ||||||||
FaxNumber: | 9287298019 | ||||||||
Practice Location | |||||||||
Address1: | CORNER OF ROUTE N12 & N7 | ||||||||
Address2: |   | ||||||||
City: | FORT DEFIANCE | ||||||||
State: | AZ | ||||||||
PostalCode: | 865040649 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9287298000 | ||||||||
FaxNumber: | 9287298019 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/27/2006 | ||||||||
LastUpdateDate: | 02/26/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FREELAND | ||||||||
AuthorizedOfficialFirstName: | FRANKLIN | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 9287298010 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | ED.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X |   |   | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 020488 | 05 | AZ |   | MEDICAID | H0010 | 05 | NM |   | MEDICAID |