Provider Demographics
NPI:1366774044
Name:NORTH COUNTRY HEALTHCARE INC.
Entity type:Organization
Organization Name:NORTH COUNTRY HEALTHCARE INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROGGENBUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-774-8325
Mailing Address - Street 1:PO BOX 3630
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-3630
Mailing Address - Country:US
Mailing Address - Phone:928-213-6121
Mailing Address - Fax:928-774-6687
Practice Address - Street 1:1 CLINIC ROAD
Practice Address - Street 2:
Practice Address - City:GRAND CANYON
Practice Address - State:AZ
Practice Address - Zip Code:86023
Practice Address - Country:US
Practice Address - Phone:928-638-2551
Practice Address - Fax:928-638-2287
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH COUNTRY HEALTHCARE INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-02-05
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZOTC3823OtherARIZONA DEPARTMENT OF HEALTH SERVICES