Basic Information
| Provider Information | |||||||||
| NPI: | 1821324948 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARANA HEALTH CENTER, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 188 | ||||||||
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| City: | MARANA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856530188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206824111 | ||||||||
| FaxNumber: | 5208183630 | ||||||||
| Practice Location | |||||||||
| Address1: | 8181 E IRVINGTON RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857094001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205741551 | ||||||||
| FaxNumber: | 5205740783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2009 | ||||||||
| LastUpdateDate: | 03/13/2019 | ||||||||
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| AuthorizedOfficialLastName: | KUNTZ | ||||||||
| AuthorizedOfficialFirstName: | CLINTON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5206824111 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MARANA HEALTH CENTER, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | OTC4723 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 329592 | 01 | AZ | AHCCCS GROUP NUMBER | OTHER | 928978 | 05 | AZ | MEDICAID |