Provider Demographics
NPI:1073373536
Name:MARIPOSA COMMUNITY HEALTH CENTER, INC
Entity Type:Organization
Organization Name:MARIPOSA COMMUNITY HEALTH CENTER, INC
Other - Org Name:
Other - Org Type:
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:85621-1061
Mailing Address - Country:US
Mailing Address - Phone:520-761-2133
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:520-375-5032
Practice Address - Fax:520-761-2159
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARIPOSA COMMUNITY HEALTH CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223D0001XDental ProvidersDentistDental Public HealthGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
1013213404OtherGROUP NPI