Basic Information
| Provider Information | |||||||||
| NPI: | 1760427587 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DHHS, PHS, NAIHS, SHIPROCK HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DZILTH-NA-O-DITH-HLE HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 160 | ||||||||
| Address2: | ATTNBUSINESS OFFICE MANAGER | ||||||||
| City: | SHIPROCK | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874200160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053686401 | ||||||||
| FaxNumber: | 5053686431 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 ROAD 7586 | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053686401 | ||||||||
| FaxNumber: | 5053686431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 07/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | COMER | ||||||||
| AuthorizedOfficialFirstName: | FANNESSA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5053686006 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | N | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QF0050X | N | Ambulatory Health Care Facilities | Clinic/Center | Family Planning, Non-Surgical | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QP0904X | N | Ambulatory Health Care Facilities | Clinic/Center | Public Health, Federal | 261QP1100X | N | Ambulatory Health Care Facilities | Clinic/Center | Podiatric | 261QP2000X | N | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | 261QR0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 261QS0112X | N | Ambulatory Health Care Facilities | Clinic/Center | Oral and Maxillofacial Surgery | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 418188 | 05 | AZ | MEDICAID | 7000000084 | 05 | UT | MEDICAID | 7000000092 | 05 | UT | MEDICAID | 89805 | 05 | NM | MEDICAID | 95017950 | 05 | CO | MEDICAID |