Provider Demographics
NPI:1083937569
Name:THE FORT DEFIANCE INDIAN HOSPITAL BOARD, INCORPORATION
Entity Type:Organization
Organization Name:THE FORT DEFIANCE INDIAN HOSPITAL BOARD, INCORPORATION
Other - Org Name:FORT DEFIANCE INDIAN HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:LS
Authorized Official - Last Name:ADKINS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:928-729-8902
Mailing Address - Street 1:PO BOX 649
Mailing Address - Street 2:
Mailing Address - City:FORT DEFIANCE
Mailing Address - State:AZ
Mailing Address - Zip Code:86504-0649
Mailing Address - Country:US
Mailing Address - Phone:928-729-8000
Mailing Address - Fax:928-729-8158
Practice Address - Street 1:CORNER OF ROUTE N12 & N7
Practice Address - Street 2:
Practice Address - City:FORT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504
Practice Address - Country:US
Practice Address - Phone:928-729-8000
Practice Address - Fax:928-729-8169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0356609OtherNCPDP NUMBER
0356609OtherNCPDP NUMBER