Provider Demographics
NPI:1184874034
Name:DHHS IHS PHOENIX AREA
Entity type:Organization
Organization Name:DHHS IHS PHOENIX AREA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:928-338-4911
Mailing Address - Street 1:P.O. BOX 860
Mailing Address - Street 2:200 HOSPITAL DRIVE
Mailing Address - City:WHITERIVER
Mailing Address - State:AZ
Mailing Address - Zip Code:85941-0860
Mailing Address - Country:US
Mailing Address - Phone:928-338-4911
Mailing Address - Fax:928-338-5508
Practice Address - Street 1:NORTH CROMWELL ROAD
Practice Address - Street 2:
Practice Address - City:CIBECUE
Practice Address - State:AZ
Practice Address - Zip Code:85911
Practice Address - Country:US
Practice Address - Phone:928-332-2560
Practice Address - Fax:928-338-5508
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DHHS IHS PHOENIX AREA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-29
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ092461Medicaid
030113Medicare Oscar/Certification