Basic Information
| Provider Information | |||||||||
| NPI: | 1861544942 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARANA HEALTH CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 188 | ||||||||
| Address2: | |||||||||
| City: | MARANA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856530188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206824560 | ||||||||
| FaxNumber: | 5206823299 | ||||||||
| Practice Location | |||||||||
| Address1: | 13395 N MARANA MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MARANA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856537008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206821095 | ||||||||
| FaxNumber: | 5206822196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 10/04/2017 | ||||||||
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| AuthorizedOfficialLastName: | KUNTZ | ||||||||
| AuthorizedOfficialFirstName: | CLINTON | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5206824111 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | 4075 | AZ | Y | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 329592 | 01 | AZ | AHCCCS GROUP NUMBER | OTHER | 510768 | 05 | AZ | MEDICAID |