Basic Information
| Provider Information | |||||||||
| NPI: | 1962949008 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SAN LUCY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | SAN LUCY CLINIC | ||||||||
| Address2: | P.O.BOX 31001-0698 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911100698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022631200 | ||||||||
| FaxNumber: | 6022631618 | ||||||||
| Practice Location | |||||||||
| Address1: | 1216 N. 307TH AVENUE | ||||||||
| Address2: | SAN LUCY CLINIC | ||||||||
| City: | GILA BEND | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286832913 | ||||||||
| FaxNumber: | 9286832008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2017 | ||||||||
| LastUpdateDate: | 06/19/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DICK | ||||||||
| AuthorizedOfficialFirstName: | DEANNA | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | (CEO) CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6022631567 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM | ||||||||
| AuthorizedOfficialNamePrefix: | MISS | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MSW,. MHA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X | Y | Agencies | Public Health or Welfare |
No ID Information.