Provider Demographics
NPI:1417330713
Name:SAN CARLOS APACHE HEALTHCARE CORPORATION
Entity Type:Organization
Organization Name:SAN CARLOS APACHE HEALTHCARE CORPORATION
Other - Org Name:CLARENCE WESLEY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERMIN CEO
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BEGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-475-1201
Mailing Address - Street 1:PO BOX 787
Mailing Address - Street 2:
Mailing Address - City:PERIDOT
Mailing Address - State:AZ
Mailing Address - Zip Code:85542-0787
Mailing Address - Country:US
Mailing Address - Phone:928-475-1200
Mailing Address - Fax:
Practice Address - Street 1:101 MEDICINE ROAD
Practice Address - Street 2:
Practice Address - City:BYLAS
Practice Address - State:AZ
Practice Address - Zip Code:85530
Practice Address - Country:US
Practice Address - Phone:928-475-7142
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-06
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center