Provider Demographics
NPI:1184838930
Name:SUN LIFE FAMILY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:SUN LIFE FAMILY HEALTH CENTER, INC.
Other - Org Name:SUN LIFE FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-836-3446
Mailing Address - Street 1:PO BOX 10097
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85130-0020
Mailing Address - Country:US
Mailing Address - Phone:520-836-3446
Mailing Address - Fax:520-836-8807
Practice Address - Street 1:110 MAIN STREET
Practice Address - Street 2:
Practice Address - City:MAMMOTH
Practice Address - State:AZ
Practice Address - Zip Code:85623
Practice Address - Country:US
Practice Address - Phone:520-487-0322
Practice Address - Fax:520-487-2463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC-3754261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FQ61788Medicare ID - Type Unspecified
AZ031828Medicare Oscar/Certification