Healthcare Provider Details

I. General information

NPI: 1992154694
Provider Name (Legal Business Name): SAN CARLOS APACHE HEALTHCARE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2016
Last Update Date: 06/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 MEDICINE WAY ROAD
PERIDOT AZ
85542
US

IV. Provider business mailing address

PO BOX 787
PERIDOT AZ
85542-0787
US

V. Phone/Fax

Practice location:
  • Phone: 928-475-1200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: VICTORIA BEGAN
Title or Position: INTERIM CEO
Credential:
Phone: 928-475-1200