Provider Demographics
NPI:1447410048
Name:MARICOPA COUNTY D.B.A. MARICOPA COUNTY DEPART
Entity Type:Organization
Organization Name:MARICOPA COUNTY D.B.A. MARICOPA COUNTY DEPART
Other - Org Name:CLINICAL SERVICES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DEPUTY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MAX
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-506-6641
Mailing Address - Street 1:1645 E ROOSEVELT STREET
Mailing Address - Street 2:CLINICAL SERVICES
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006
Mailing Address - Country:US
Mailing Address - Phone:602-506-6660
Mailing Address - Fax:602-372-0342
Practice Address - Street 1:1645 E. ROOSEVELT STREET
Practice Address - Street 2:CLINICAL SERVICES
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006
Practice Address - Country:US
Practice Address - Phone:608-506-6660
Practice Address - Fax:602-375-0342
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARICOPA COUNTYD.B.A. MARICOPA COUNTY DEPARTMENT OF HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-17
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC3761261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ097451Medicaid