Healthcare Provider Details

I. General information

NPI: 1396022026
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: 12/13/2022
Certification Date: 12/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 PALO VERDE
HAVASU LAKE CA
92363
US

IV. Provider business mailing address

1970 PALO VERDE DRIVE
HAVASU LAKE CA
92363-1858
US

V. Phone/Fax

Practice location:
  • Phone: 760-858-4790
  • Fax: 928-669-3232
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP0904X
TaxonomyFederal Public Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SKY RAINBOW BLACK ELK-VOLKMANN
Title or Position: SUPERVISOR, PATIENT BUSINESS OFFC.
Credential:
Phone: 605-384-4844