Basic Information
Provider Information | |||||||||
NPI: | 1760735468 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TCRHCC MOBILE HEALTHCARE VAN SYSTEM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BODAWAY/GAP CHAPTER HOUSE | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 600 | ||||||||
Address2: | BASE OF OPERATIONS: 167 N. MAIN ST. TUBA CITY, AZ 86045 | ||||||||
City: | TUBA CITY | ||||||||
State: | AZ | ||||||||
PostalCode: | 860450600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9282832781 | ||||||||
FaxNumber: | 9282832677 | ||||||||
Practice Location | |||||||||
Address1: | HIGHWAY 89 AT MILE POST 498 | ||||||||
Address2: | BODAWAY/GAP CHAPTER HOUSE | ||||||||
City: | GAP | ||||||||
State: | AZ | ||||||||
PostalCode: | 86020 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9282832501 | ||||||||
FaxNumber: | 9282832677 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/18/2012 | ||||||||
LastUpdateDate: | 10/24/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ENGELKEN | ||||||||
AuthorizedOfficialFirstName: | JOSEPH | ||||||||
AuthorizedOfficialMiddleName: | T | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 9282832501 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | TUBA CITY REGIONAL HEALTH CARE CORPORATION | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
No ID Information.