=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811962848
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COBRE VALLEY REGIONAL MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2006
-----------------------------------------------------
Last Update Date | 08/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 124 N TEWKSBURY BLVD
-----------------------------------------------------
City | YOUNG
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-462-3435
-----------------------------------------------------
Fax | 928-462-6644
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 177
-----------------------------------------------------
City | YOUNG
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85554-0177
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-462-3435
-----------------------------------------------------
Fax | 928-462-6644
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | NEAL D. JENSEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 928-425-3261
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number | OTC 0508
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------