Provider Demographics
NPI:1417204157
Name:MARICOPA COUNTY DBA MARICOPA COUNTY OF PUBLIC HEALTH SERVICES DBA PUBL
Entity Type:Organization
Organization Name:MARICOPA COUNTY DBA MARICOPA COUNTY OF PUBLIC HEALTH SERVICES DBA PUBL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CORINNE
Authorized Official - Middle Name:
Authorized Official - Last Name:VELASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-506-6657
Mailing Address - Street 1:1645 E. ROOSEVELT STREET
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006
Mailing Address - Country:US
Mailing Address - Phone:602-506-6997
Mailing Address - Fax:602-372-0342
Practice Address - Street 1:1645 E ROOSEVELT STREET
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006
Practice Address - Country:US
Practice Address - Phone:602-506-6997
Practice Address - Fax:602-372-0342
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARICOPA COUNTY DBA MARICOPA COUNTY OF PUBLIC HEALTH SERVICES DBA PUBL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ016291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ099267Medicaid