Basic Information
Provider Information
NPI: 1083839476
EntityType: 2
ReplacementNPI:  
OrganizationName: DHHS, PHS, NAIHS, SHIPROCK HOSPITAL
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: SANOSTEE HEALTH STATION
OtherOrganizationType: 5
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: IN CARE OF NORTHERN NAVAJO MEDICAL CENTER
Address2: PO BOX 160
City: SHIPROCK
State: NM
PostalCode: 87420
CountryCode: US
TelephoneNumber: 5053686001
FaxNumber: 5053686431
Practice Location
Address1: NAVAJO ROUTE 34
Address2:  
City: SANOSTEE
State: NM
PostalCode: 87461
CountryCode: US
TelephoneNumber: 5053686001
FaxNumber: 5053686431
Other Information
ProviderEnumerationDate: 04/13/2007
LastUpdateDate: 07/11/2008
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: COMER
AuthorizedOfficialFirstName: FANNESSA
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CEO
AuthorizedOfficialTelephone: 5053686006
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261Q00000X  N Ambulatory Health Care FacilitiesClinic/Center 
261QC1500X  N Ambulatory Health Care FacilitiesClinic/CenterCommunity Health
261QF0050X  N Ambulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
261QS1000X  N Ambulatory Health Care FacilitiesClinic/CenterStudent Health
282N00000X  Y HospitalsGeneral Acute Care Hospital 

ID Information
IDTypeStateIssuerDescription
9617405605NM MEDICAID


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