Basic Information
| Provider Information | |||||||||
| NPI: | 1851600191 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GILA RIVER HEALTH CARE CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10 | ||||||||
| Address2: | |||||||||
| City: | SACATON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851470001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025281200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 483 W. SEED FARM ROAD | ||||||||
| Address2: | |||||||||
| City: | SACATON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851470001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025281200 | ||||||||
| FaxNumber: | 6025281374 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2010 | ||||||||
| LastUpdateDate: | 10/05/2010 | ||||||||
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| AuthorizedOfficialLastName: | BETSINGER | ||||||||
| AuthorizedOfficialFirstName: | SYBIL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CASE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6025281200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | LCSW-11718 | AZ | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 346214 | 05 | AZ | MEDICAID |