MEDICARE: INTERMOUNTAIN HEALTH CENTER INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency
2	261QM1300X	Multi-Specialty Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OTC7779	OTHER	AZ	ADHS/BMFL LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609245273
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERMOUNTAIN HEALTH CENTER INC

Provider Business Mailing Address
First Line	:	PO BOX 86537
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85754-6537
Country	:	US
Telephone Number	:	520-721-1887
Fax Number	:	520-721-0069

Provider Business Practice Location Address
First Line	:	5055 E BROADWAY BLVD STE C104
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85711-3641
Country	:	US
Telephone Number	:	520-628-9833
Fax Number	:	520-623-9083

Authorized Official
Title or Position	:	PRESIDENT AND CEO
Name	:	ROSE MARY LOPEZ
Credential	:	MBA
Telephone Number	:	520-721-1887

Provider Enumeration Date	:	09/24/2015
Last Update Date	:	02/29/2024

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Directions to “INTERMOUNTAIN HEALTH CENTER INC ” Practice Location

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