Basic Information
| Provider Information | |||||||||
| NPI: | 1114141876 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DHHS, PHS, NAIHS, SHIPROCK HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | DZILTH NA O DITH HLE HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6 ROAD 7586 | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874134934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053686401 | ||||||||
| FaxNumber: | 5053686431 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 ROAD 7586 | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874134934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053686001 | ||||||||
| FaxNumber: | 5053686431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 12/05/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COMER | ||||||||
| AuthorizedOfficialFirstName: | FANNESSA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5053686006 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 7000000092 | 05 | UT | MEDICAID | 89805 | 05 | NM | MEDICAID | 418188 | 05 | AZ | MEDICAID | 7000000084 | 05 | UT | MEDICAID | 95017950 | 05 | CO | MEDICAID |