Basic Information
| Provider Information | |||||||||
| NPI: | 1356628028 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DHHS IHS PHOENIX AREA | ||||||||
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| OtherOrganizationName: | HOPI HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | HIGHWAY 264 MILEPOST 388 | ||||||||
| Address2: | PO BOX 4000 | ||||||||
| City: | POLACCA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860424000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287376000 | ||||||||
| FaxNumber: | 9287376080 | ||||||||
| Practice Location | |||||||||
| Address1: | HIGHWAY 264 MILEPOST 388 | ||||||||
| Address2: | |||||||||
| City: | POLACCA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860424000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287376000 | ||||||||
| FaxNumber: | 9287376080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2011 | ||||||||
| LastUpdateDate: | 05/24/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MELVIN | ||||||||
| AuthorizedOfficialFirstName: | DARYL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9287376010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 122300000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 133N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Nutritionist | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 163W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 364S00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | 282NC0060X | 366937 | AZ | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 861717 | 05 | AZ | MEDICAID | 020529 | 05 | AZ | MEDICAID |