Basic Information
| Provider Information | |||||||||
| NPI: | 1821309089 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHIRICAHUA COMMUNITY HEALTH CENTERS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1205 F AVE | ||||||||
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| City: | DOUGLAS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856071920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203641429 | ||||||||
| FaxNumber: | 5203644261 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 CALLE PORTAL | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | SIERRA VISTA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856352900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204593011 | ||||||||
| FaxNumber: | 5203644261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2010 | ||||||||
| LastUpdateDate: | 09/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | MELK | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5203646852 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 09/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 945865 | 05 | AZ | MEDICAID |