Basic Information
| Provider Information | |||||||||
| NPI: | 1952526337 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DHHS, PHS, NAIHS, SHIPROCK HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TOADLENA HEALTH CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 160 | ||||||||
| Address2: | IN CARE OF NORTHERN NAVAJO MEDICAL CENTER | ||||||||
| City: | SHIPROCK | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053686001 | ||||||||
| FaxNumber: | 5053686431 | ||||||||
| Practice Location | |||||||||
| Address1: | NAVAJO ROUTE 19 | ||||||||
| Address2: | |||||||||
| City: | TOADLENA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053686001 | ||||||||
| FaxNumber: | 5053686431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2007 | ||||||||
| 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 | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QC1500X | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QS1000X | N | Ambulatory Health Care Facilities | Clinic/Center | Student Health | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 33901546 | 05 | NM | MEDICAID |