Provider Demographics
NPI:1114218385
Name:EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER, INC
Entity Type:Organization
Organization Name:EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER, INC
Other - Org Name:EL RIIO NORTHWEST HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-309-2012
Mailing Address - Street 1:839 W CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-2819
Mailing Address - Country:US
Mailing Address - Phone:520-670-3909
Mailing Address - Fax:
Practice Address - Street 1:320 W PRINCE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-3526
Practice Address - Country:US
Practice Address - Phone:520-670-3909
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-22
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC3588261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ947903Medicaid
AZ031899Medicare Oscar/Certification