Healthcare Provider Details

I. General information

NPI: 1841206257
Provider Name (Legal Business Name): GILA CROSSING CLINIC PHCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9975 E BELTLINE RD
LAVEEN AZ
85339
US

IV. Provider business mailing address

PO BOX 380
LAVEEN AZ
85339-0380
US

V. Phone/Fax

Practice location:
  • Phone: 602-528-1422
  • Fax: 602-528-3363
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: LOREN ELLORY
Title or Position: CEO
Credential:
Phone: 602-528-1200