Basic Information
| Provider Information | |||||||||
| NPI: | 1861661365 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HUPA HEALTH ASSOCIATION INC AMBULANCE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1288 | ||||||||
| Address2: | 1200 AIRPORT RD | ||||||||
| City: | HOOPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955461288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306254261 | ||||||||
| FaxNumber: | 5306259308 | ||||||||
| Practice Location | |||||||||
| Address1: | 535 AIRPORT RD | ||||||||
| Address2: | |||||||||
| City: | HOOPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955469615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306254261 | ||||||||
| FaxNumber: | 5306259308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2008 | ||||||||
| LastUpdateDate: | 10/21/2019 | ||||||||
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| AuthorizedOfficialLastName: | CHASE | ||||||||
| AuthorizedOfficialFirstName: | EMMETT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5306254261 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | K'IMAW MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CEO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | EXEMPT INDIAN TRIBE | CA | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | ZZZ84024Z | 05 | CA | MEDICAID |