Basic Information
| Provider Information | |||||||||
| NPI: | 1952704173 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WICKENBURG COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BANNER HEALTH SYSTEMS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 ROSE LN | ||||||||
| Address2: | |||||||||
| City: | WICKENBURG | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853901447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286845529 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12023 W WINDROSE DR | ||||||||
| Address2: | |||||||||
| City: | EL MIRAGE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853354323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015704006 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2014 | ||||||||
| LastUpdateDate: | 10/01/2014 | ||||||||
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| AuthorizedOfficialLastName: | LITTELL | ||||||||
| AuthorizedOfficialFirstName: | TARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9286845529 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT, DPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NR1301X | 9016 | AZ | Y | Hospitals | General Acute Care Hospital | Rural |
No ID Information.