Basic Information
| Provider Information | |||||||||
| NPI: | 1710475124 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN CARLOS APACHE HEALTHCARE CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 787 | ||||||||
| Address2: | |||||||||
| City: | PERIDOT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855420787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284751290 | ||||||||
| FaxNumber: | 9284757371 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 MEDICINE WAY ROAD | ||||||||
| Address2: | |||||||||
| City: | PERIDOT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284751400 | ||||||||
| FaxNumber: | 9284757371 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2018 | ||||||||
| LastUpdateDate: | 05/01/2018 | ||||||||
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| AuthorizedOfficialLastName: | CHEE | ||||||||
| AuthorizedOfficialFirstName: | VALERIE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR PATIENT FINANCIAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 9284751290 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 059898 | 05 | AZ | MEDICAID | 099458 | 05 | AZ | MEDICAID |