Basic Information
| Provider Information | |||||||||
| NPI: | 1376773341 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TUBA CITY REGIONAL HEALTH CARE CORPORATION | ||||||||
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| OtherOrganizationName: | SACRED PEAKS HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 600 | ||||||||
| Address2: | |||||||||
| City: | TUBA CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860450600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282832501 | ||||||||
| FaxNumber: | 9282832677 | ||||||||
| Practice Location | |||||||||
| Address1: | 6300 N HIGHWAY 89 | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9288637333 | ||||||||
| FaxNumber: | 9285250047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2009 | ||||||||
| LastUpdateDate: | 09/10/2019 | ||||||||
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| AuthorizedOfficialLastName: | BONAR | ||||||||
| AuthorizedOfficialFirstName: | LYNETTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9282832944 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TUBA CITY REGIONAL HEALTH CARE CORPORATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085U0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 291U00000X | N | Laboratories | Clinical Medical Laboratory | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 721250 | 05 | AZ | MEDICAID |