Healthcare Provider Details

I. General information

NPI: 1689804387
Provider Name (Legal Business Name): DHHS PHS NAIHS SHIPROCK HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2009
Last Update Date: 07/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HWY 160 & NAVAJO ROUTE 25 - RED MESA
TEENNOSPOS AZ
86514
US

IV. Provider business mailing address

HCR 6100, BOX 30
TEECNOSPOS AZ
86514
US

V. Phone/Fax

Practice location:
  • Phone: 928-656-5000
  • Fax: 928-656-5164
Mailing address:
  • Phone: 928-656-5000
  • Fax: 928-656-5164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number03D1068558
License Number State

VIII. Authorized Official

Name: FANNESSA COMER
Title or Position: CEO
Credential:
Phone: 505-368-6001