Provider Demographics
NPI:1033213053
Name:NORTHLAND CARES
Entity Type:Organization
Organization Name:NORTHLAND CARES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-776-4612
Mailing Address - Street 1:3112 CLEARWATER DR STE A
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-7187
Mailing Address - Country:US
Mailing Address - Phone:928-776-4612
Mailing Address - Fax:928-771-1767
Practice Address - Street 1:3112 CLEARWATER DR STE A
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-7187
Practice Address - Country:US
Practice Address - Phone:928-776-4612
Practice Address - Fax:928-771-1767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251V00000X
AZ1033213053261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
1598778177OtherNPI
1033213053OtherNATIONAL PROVIDER IDENTIFIER
AZ402329Medicaid
AZ1356370571OtherNATIONAL PROVIDER IDENTIFIER
AZ402329Medicaid