Provider Demographics
NPI:1023378825
Name:PEACH SPRINGS INDIAN HEALTH CENTER
Entity Type:Organization
Organization Name:PEACH SPRINGS INDIAN HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL NURSE
Authorized Official - Prefix:
Authorized Official - First Name:RANDI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:928-699-8879
Mailing Address - Street 1:943 HUALAPAI WAY
Mailing Address - Street 2:
Mailing Address - City:PEACH SPRINGS
Mailing Address - State:AZ
Mailing Address - Zip Code:86434-0190
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:943 HUALAPAI WAY
Practice Address - Street 2:
Practice Address - City:PEACH SPRINGS
Practice Address - State:AZ
Practice Address - Zip Code:86434-0190
Practice Address - Country:US
Practice Address - Phone:928-769-2900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DHHS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-25
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN167054261QP0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal