MEDICARE: STATE OF ARIZONA/STATE DEPT OF FINANCE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1093438053
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF ARIZONA/STATE DEPT OF FINANCE

Provider Business Mailing Address
First Line	:	2100 N GEMINI DR
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001-1625
Country	:	US
Telephone Number	:	602-255-3373
Fax Number	:

Provider Business Practice Location Address
First Line	:	2100 N GEMINI DR
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001-1625
Country	:	US
Telephone Number	:	602-255-3373
Fax Number	:

Authorized Official
Title or Position	:	CENTRAL BILLER
Name	:	LAURIE A CHAPMAN
Credential	:
Telephone Number	:	480-318-0920

Provider Enumeration Date	:	09/23/2022
Last Update Date	:	12/19/2022

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