Provider Demographics
NPI:1417403007
Name:MARANA HEALTH CENTER, INC
Entity Type:Organization
Organization Name:MARANA HEALTH CENTER, INC
Other - Org Name:DOVE MOUNTAIN HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CLINT
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:520-616-1442
Practice Address - Street 1:5224 W DOVE CENTRE RD
Practice Address - Street 2:
Practice Address - City:MARANA
Practice Address - State:AZ
Practice Address - Zip Code:85658-5063
Practice Address - Country:US
Practice Address - Phone:520-616-1445
Practice Address - Fax:520-616-1446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC7878261QF0400X, 261QM0801X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ210156Medicaid
AZ329592OtherGROUP MEDICAID
AZ329592OtherGROUP MEDICAID
AZ210156Medicaid