Provider Demographics
NPI:1245399468
Name:MARANA HEALTH CENTER, INC
Entity Type:Organization
Organization Name:MARANA HEALTH CENTER, INC
Other - Org Name:FLOWING WELLS FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:
Authorized Official - Last Name:KUNTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-682-4111
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85653-0188
Mailing Address - Country:US
Mailing Address - Phone:520-682-4111
Mailing Address - Fax:520-818-3630
Practice Address - Street 1:1323 W PRINCE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-3114
Practice Address - Country:US
Practice Address - Phone:520-887-0800
Practice Address - Fax:520-887-1393
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARANA HEALTH CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-06
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ417786Medicaid
AZ329592OtherAHCCCS GROUP NUMBER
AZ417786Medicaid
AZZWMBRVMedicare PIN