Healthcare Provider Details

I. General information

NPI: 1760735468
Provider Name (Legal Business Name): TCRHCC MOBILE HEALTHCARE VAN SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2012
Last Update Date: 10/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HIGHWAY 89 AT MILE POST 498 BODAWAY/GAP CHAPTER HOUSE
GAP AZ
86020
US

IV. Provider business mailing address

PO BOX 600 BASE OF OPERATIONS: 167 N. MAIN ST. TUBA CITY, AZ 86045
TUBA CITY AZ
86045-0600
US

V. Phone/Fax

Practice location:
  • Phone: 928-283-2501
  • Fax: 928-283-2677
Mailing address:
  • Phone: 928-283-2781
  • Fax: 928-283-2677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH T ENGELKEN
Title or Position: CEO
Credential:
Phone: 928-283-2501