Healthcare Provider Details

I. General information

NPI: 1841354263
Provider Name (Legal Business Name): SAN CARLOS APACHE TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 02/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLD 15 SAN CARLOS AVENUE
SAN CARLOS AZ
85550
US

IV. Provider business mailing address

PO BOX 0 HWY 70 MOONBASE ROAD
SAN CARLOS AZ
85550-0000
US

V. Phone/Fax

Practice location:
  • Phone: 928-475-4221
  • Fax: 928-475-2885
Mailing address:
  • Phone: 928-475-2798
  • Fax: 928-475-4009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number
License Number StateAZ

VIII. Authorized Official

Name: MS. CHERRILL WILLIAMS
Title or Position: DIRECTOR
Credential:
Phone: 928-475-4221