Provider Demographics
NPI:1487716650
Name:CARONDELET ST. MARY'S NORTHWEST, LLC
Entity type:Organization
Organization Name:CARONDELET ST. MARY'S NORTHWEST, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER / AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENETHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-763-3893
Mailing Address - Street 1:2220 W ORANGE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85741-3117
Mailing Address - Country:US
Mailing Address - Phone:520-877-5660
Mailing Address - Fax:520-877-5669
Practice Address - Street 1:2220 W ORANGE GROVE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-3117
Practice Address - Country:US
Practice Address - Phone:520-877-5660
Practice Address - Fax:520-877-5669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOSC3857261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ006486Medicaid
AZ03C0001289OtherCCN
AZ03C0001289OtherCCN