Basic Information
| Provider Information | |||||||||
| NPI: | 1962770370 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EL RIO-PASCUA CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 839 W CONGRESS ST | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857452819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208796225 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7490 S CAMINO DE OESTE | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857469308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208796225 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2011 | ||||||||
| LastUpdateDate: | 07/15/2016 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5203092012 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 947930 | 05 | AZ | MEDICAID |