Basic Information
| Provider Information | |||||||||
| NPI: | 1750691788 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH COUNTRY HEALTHCARE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3630 | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860033630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285229400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | WILLIAMS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860460110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286354441 | ||||||||
| FaxNumber: | 9286354403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2010 | ||||||||
| LastUpdateDate: | 01/12/2022 | ||||||||
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| AuthorizedOfficialLastName: | NEWLAND | ||||||||
| AuthorizedOfficialFirstName: | ANNE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9285229400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTH COUNTRY HEALTHCARE, INC. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 01/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QM1300X | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 908079 | 05 | AZ | MEDICAID |