Healthcare Provider Details

I. General information

NPI: 1730310046
Provider Name (Legal Business Name): GREENLEE COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2009
Last Update Date: 08/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 5TH STREET
CLIFTON AZ
85533-0936
US

IV. Provider business mailing address

PO BOX 936 253 5TH STREET
CLIFTON AZ
85533-0936
US

V. Phone/Fax

Practice location:
  • Phone: 928-865-2601
  • Fax: 928-865-1929
Mailing address:
  • Phone: 928-865-2601
  • Fax: 928-865-1929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0005X
TaxonomyAmbulatory Family Planning Facility
License NumberOTC0267
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code261QP2400X
TaxonomyPrison Health Clinic/Center
License NumberOTC0267
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License NumberOTC0267
License Number StateAZ

VIII. Authorized Official

Name: MR. DARREN C SANDERS
Title or Position: DEPUTY DIRECTOR HEALTH AND COUNTY
Credential:
Phone: 928-865-2601