Provider Demographics
NPI:1134472111
Name:TCRHCC MOBILE HEALTHCARE VAN SYSTEM
Entity Type:Organization
Organization Name:TCRHCC MOBILE HEALTHCARE VAN SYSTEM
Other - Org Name:KAIBETO CHAPTER-DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:T
Authorized Official - Last Name:ENGELKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-283-2501
Mailing Address - Street 1:PO BOX 600
Mailing Address - Street 2:BASE OF OPERATIONS: 167 NORTH MAIN STREET
Mailing Address - City:TUBA CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86045-0600
Mailing Address - Country:US
Mailing Address - Phone:928-283-2781
Mailing Address - Fax:928-283-2677
Practice Address - Street 1:35 MI N OF JCT HWY 160 &HWY 98
Practice Address - Street 2:KAIBETO CHAPTER HOUSE-DENTAL
Practice Address - City:KAIBETO
Practice Address - State:AZ
Practice Address - Zip Code:86053
Practice Address - Country:US
Practice Address - Phone:928-283-2501
Practice Address - Fax:928-283-2677
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TUBA CITY REGIONAL HEALTH CARE CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-16
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center