Basic Information
| Provider Information | |||||||||
| NPI: | 1972789667 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VERDE VALLEY MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VVMC GUARDIAN AIR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 N BEAVER ST | ||||||||
| Address2: | ATTN: MANAGED CARE CONTRACTING | ||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860013118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282136543 | ||||||||
| FaxNumber: | 9282143613 | ||||||||
| Practice Location | |||||||||
| Address1: | 269 S CANDY LN | ||||||||
| Address2: | |||||||||
| City: | COTTONWOOD | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863264158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287792546 | ||||||||
| FaxNumber: | 9282136292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2008 | ||||||||
| LastUpdateDate: | 04/15/2019 | ||||||||
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| AuthorizedOfficialLastName: | HAASE | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | NAH CHIEF SYSTEMS OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9287732059 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VERDE VALLEY MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416A0800X | N | Transportation Services | Ambulance | Air Transport | 3416A0800X | AZ | Y | Transportation Services | Ambulance | Air Transport |
ID Information
| ID | Type | State | Issuer | Description | XMTA05974 | 05 | AZ | MEDICAID | 804816 | 05 | AZ | MEDICAID | P0152150 | 01 | AZ | BCBS | OTHER | P0152150 | 01 | AZ | BCBS SECONDARY | OTHER |