Basic Information
| Provider Information | |||||||||
| NPI: | 1659624633 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY HEALTH CENTER MOBILE HEALTH PROGRAM | ||||||||
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| OtherOrganizationName: | COMMUNITY HEALTH MOBILE DENTAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 600 | ||||||||
| Address2: | BASE OF OPERATIONS: 167 NORTH MAIN STREET | ||||||||
| City: | TUBA CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860450600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282832781 | ||||||||
| FaxNumber: | 9282832677 | ||||||||
| Practice Location | |||||||||
| Address1: | 167 NORTH MAIN STREET, BASE OF OPERATIONS | ||||||||
| Address2: | SERVICE AREA: WESTERN NAVAJO AGENCY W/IN AZ | ||||||||
| City: | TUBA CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860450600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282832781 | ||||||||
| FaxNumber: | 9282832677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2012 | ||||||||
| LastUpdateDate: | 04/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | ENGELKEN | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9282832501 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TUBA CITY REGIONAL HEALTH CARE CORPORATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.