Healthcare Provider Details

I. General information

NPI: 1487175162
Provider Name (Legal Business Name): CHIRICAHUA COMMUNITY HEALTH CENTERS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 09/01/2021
Certification Date: 09/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 CAMPUS DR
SIERRA VISTA AZ
85635-2449
US

IV. Provider business mailing address

1205 F AVE
DOUGLAS AZ
85607-1920
US

V. Phone/Fax

Practice location:
  • Phone: 520-459-3011
  • Fax: 520-364-4261
Mailing address:
  • Phone: 520-364-6852
  • Fax: 520-364-4261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License NumberOTC8372
License Number StateAZ

VIII. Authorized Official

Name: JONATHAN P MELK
Title or Position: CEO
Credential:
Phone: 520-364-6852