Basic Information
| Provider Information | |||||||||
| NPI: | 1972869014 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INDIAN HEALTH SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CHINLE HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2359 | ||||||||
| Address2: | |||||||||
| City: | CHINLE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 865032359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286747001 | ||||||||
| FaxNumber: | 9286747008 | ||||||||
| Practice Location | |||||||||
| Address1: | HWY 191 AND HOSPITAL DRIVE | ||||||||
| Address2: | CHINLE HOSPITAL | ||||||||
| City: | CHINLE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286747001 | ||||||||
| FaxNumber: | 9286747008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2012 | ||||||||
| LastUpdateDate: | 04/03/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GEISHEKER | ||||||||
| AuthorizedOfficialFirstName: | MARTHA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | NURSE PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 9286747001 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | ANP,WHCNP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 284300000X | 091000518 | OR | Y | Hospitals | Special Hospital |
No ID Information.