Provider Demographics
NPI: | 1013213404 |
---|---|
Name: | MARIPOSA COMMUNITY HEALTH CENTER, INC |
Entity Type: | Organization |
Organization Name: | MARIPOSA COMMUNITY HEALTH CENTER, INC |
Other - Org Name: | MARIPOSA COMMUNITY HEALTH CENTER, INC - DENTAL, RIO RICO |
Other - Org Type: | Other Name |
Authorized Official - Title/Position: | CHIEF EXECUTIVE OFFICER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | DANIEL |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | PREVOST |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 520-761-2128 |
Mailing Address - Street 1: | 825 N GRAND AVE STE 100 |
Mailing Address - Street 2: | |
Mailing Address - City: | NOGALES |
Mailing Address - State: | AZ |
Mailing Address - Zip Code: | 85621-2385 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 520-761-2128 |
Mailing Address - Fax: | 520-281-1112 |
Practice Address - Street 1: | 1103 CIRCULO MERCADO |
Practice Address - Street 2: | |
Practice Address - City: | RIO RICO |
Practice Address - State: | AZ |
Practice Address - Zip Code: | 85648-6248 |
Practice Address - Country: | US |
Practice Address - Phone: | 520-281-1550 |
Practice Address - Fax: | 520-281-4487 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | MARIPOSA COMMUNITY HEALTH CENTER, INC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2011-02-01 |
Last Update Date: | 2024-04-10 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 261QF0400X | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | Group - Multi-Specialty |
No | 122300000X | Dental Providers | Dentist | Group - Multi-Specialty | |
No | 1223D0001X | Dental Providers | Dentist | Dental Public Health | Group - Multi-Specialty |
No | 1223X0400X | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics | Group - Multi-Specialty |
No | 124Q00000X | Dental Providers | Dental Hygienist | Group - Multi-Specialty | |
No | 126800000X | Dental Providers | Dental Assistant | Group - Multi-Specialty | |
No | 163W00000X | Nursing Service Providers | Registered Nurse | Group - Multi-Specialty | |
No | 164W00000X | Nursing Service Providers | Licensed Practical Nurse | Group - Multi-Specialty | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 208D00000X | Allopathic & Osteopathic Physicians | General Practice | Group - Multi-Specialty | |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
AZ | 931874 | Medicaid | |
AZ | ZFQ03-1885 | Other | MEDICARE PART B GROUP # |
AZ | 931874 | Medicaid |