Basic Information
| Provider Information | |||||||||
| NPI: | 1992967780 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COBRE VALLEY REGIONAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KEARNY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 519 | ||||||||
| Address2: | |||||||||
| City: | KEARNY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852370519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203635573 | ||||||||
| FaxNumber: | 5203635611 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 S TILBURY DR | ||||||||
| Address2: | |||||||||
| City: | KEARNY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203635573 | ||||||||
| FaxNumber: | 5203635611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2008 | ||||||||
| LastUpdateDate: | 08/09/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STAPLETON | ||||||||
| AuthorizedOfficialFirstName: | FRANK | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL CLINICS DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9284021131 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | H0126 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 1992967780 | 01 | NPI | OTHER | 934437 | 05 | AZ | MEDICAID |