=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790038743
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DHHS IHS PHOENIX AREA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2012
-----------------------------------------------------
Last Update Date | 10/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | HIGHWAY 70, MP 295.6
-----------------------------------------------------
City | BYLAS
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-475-2686
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 149
-----------------------------------------------------
City | BYLAS
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85530-0149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-475-2686
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE OFFICER
-----------------------------------------------------
Name | MRS. SHIRLEY M BONI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 928-475-7348
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------