Basic Information
Provider Information | |||||||||
NPI: | 1871972182 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NATIVE HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NATIVE AMERICAN COMMUNITY HEALTH CENTER, INC. | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4041 N. CENTRAL AVE | ||||||||
Address2: | BUILDING C | ||||||||
City: | PHEONIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850123313 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6022795262 | ||||||||
FaxNumber: | 6022795390 | ||||||||
Practice Location | |||||||||
Address1: | 2423 W DUNLAP AVE STE 140 | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850215818 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6022795351 | ||||||||
FaxNumber: | 6022795361 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/20/2015 | ||||||||
LastUpdateDate: | 07/31/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MURILLO | ||||||||
AuthorizedOfficialFirstName: | WALTER | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 6022795262 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | NATIVE HEALTH | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 936906 | 05 | AZ |   | MEDICAID |