Provider Demographics
NPI:1356510010
Name:VERDE VALLEY MEDICAL CENTER
Entity Type:Organization
Organization Name:VERDE VALLEY MEDICAL CENTER
Other - Org Name:VERDE VALLEY MEDICAL CENTER DME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NAH CHIEF SYSTEMS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:F
Authorized Official - Last Name:HAASE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-773-2059
Mailing Address - Street 1:1200 N BEAVER ST
Mailing Address - Street 2:ATTN: MANAGED CARE CONTRACTING
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3118
Mailing Address - Country:US
Mailing Address - Phone:928-213-6543
Mailing Address - Fax:928-214-3613
Practice Address - Street 1:269 S CANDY LN
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4158
Practice Address - Country:US
Practice Address - Phone:928-773-2546
Practice Address - Fax:928-213-6292
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VERDE VALLEY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-27
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH122332B00000X
AZ332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0364390002OtherMEDICARE SUPPLIER NUMBER