Provider Demographics
NPI:1447204367
Name:COUNTY OF MARICOPA
Entity Type:Organization
Organization Name:COUNTY OF MARICOPA
Other - Org Name:HEALTH CARE FOR THE HOMELESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEJONGE-RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:602-372-2101
Mailing Address - Street 1:220 S 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85007-3101
Mailing Address - Country:US
Mailing Address - Phone:602-372-2100
Mailing Address - Fax:602-372-2107
Practice Address - Street 1:220 S 12TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85007-3101
Practice Address - Country:US
Practice Address - Phone:602-372-2100
Practice Address - Fax:602-372-2107
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PUBLIC HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-22
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC 3232261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ155748Medicaid