Healthcare Provider Details

I. General information

NPI: 1669911764
Provider Name (Legal Business Name): NORTH COUNTRY HEALTHCARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2017
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 S YALE ST STE 252
FLAGSTAFF AZ
86001-7304
US

IV. Provider business mailing address

PO BOX 3630
FLAGSTAFF AZ
86003-3630
US

V. Phone/Fax

Practice location:
  • Phone: 928-774-1811
  • Fax: 928-774-2001
Mailing address:
  • Phone: 928-522-9400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: ANNE NEWLAND
Title or Position: CEO
Credential: MD
Phone: 928-522-9400