Healthcare Provider Details

I. General information

NPI: 1356628028
Provider Name (Legal Business Name): DHHS IHS PHOENIX AREA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2011
Last Update Date: 05/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HIGHWAY 264 MILEPOST 388
POLACCA AZ
86042-4000
US

IV. Provider business mailing address

HIGHWAY 264 MILEPOST 388 PO BOX 4000
POLACCA AZ
86042-4000
US

V. Phone/Fax

Practice location:
  • Phone: 928-737-6000
  • Fax: 928-737-6080
Mailing address:
  • Phone: 928-737-6000
  • Fax: 928-737-6080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number366937
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number StateNULL
# 9
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number StateNULL
# 10
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 11
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number StateNULL

VIII. Authorized Official

Name: DARYL MELVIN
Title or Position: CEO
Credential:
Phone: 928-737-6010