Basic Information
| Provider Information | |||||||||
| NPI: | 1477615789 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DHHS, PHS, NAIHS, SHIPROCK HOSPITAL | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FOUR CORNERS REGIONAL HEALTH CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 160 | ||||||||
| Address2: | |||||||||
| City: | SHIPROCK | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874200160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053686401 | ||||||||
| FaxNumber: | 5053686431 | ||||||||
| Practice Location | |||||||||
| Address1: | US HWY 160 & NAVAJO ROUTE 35 - RED MESA | ||||||||
| Address2: | |||||||||
| City: | TEECNOSPOS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053686401 | ||||||||
| FaxNumber: | 5053686431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 01/07/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COMER | ||||||||
| AuthorizedOfficialFirstName: | FANNESSA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5053686005 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QD0000X | N | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QE0002X | N | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care | 261QH0700X | N | Ambulatory Health Care Facilities | Clinic/Center | Hearing and Speech | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QP1100X | N | Ambulatory Health Care Facilities | Clinic/Center | Podiatric | 261QP2000X | N | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 282586 | 05 | AZ | MEDICAID | 7000000084 | 05 | UT | MEDICAID | 7000000092 | 05 | UT | MEDICAID | 61109321 | 05 | NM | MEDICAID | 37256718 | 05 | CO | MEDICAID |