Healthcare Provider Details

I. General information

NPI: 1891727863
Provider Name (Legal Business Name): AZ BD OF REGENTS FOR ON BEHALF OF NORTHERN AZ UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 08/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 S SAN FRANCISCO ST BLDG 25 NORTHERN ARIZONA UNIVERSITY CAMPUS
FLAGSTAFF AZ
86011-0001
US

IV. Provider business mailing address

PO BOX 6033
FLAGSTAFF AZ
86011-6033
US

V. Phone/Fax

Practice location:
  • Phone: 928-523-6343
  • Fax: 928-523-5730
Mailing address:
  • Phone: 928-523-6343
  • Fax: 928-523-5730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number3E115
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number03D0057902
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberY005336
License Number StateAZ
# 5
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberOTC5149
License Number StateAZ

VIII. Authorized Official

Name: DR. JOHN D HAEGER
Title or Position: PRESIDENT
Credential: PHD LCSW LCAS RN
Phone: 928-523-6343