Provider Demographics
NPI:1003222951
Name:NORTH COUNTRY HEALTHCARE-PONDEROSA HS
Entity Type:Organization
Organization Name:NORTH COUNTRY HEALTHCARE-PONDEROSA HS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNGBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-522-9568
Mailing Address - Street 1:PO BOX 3630
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-3630
Mailing Address - Country:US
Mailing Address - Phone:928-522-9410
Mailing Address - Fax:928-522-9411
Practice Address - Street 1:2384 N STEVES BLVD
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-6105
Practice Address - Country:US
Practice Address - Phone:928-522-9410
Practice Address - Fax:928-522-9411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-10
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty