Provider Demographics
NPI:1477615789
Name:DHHS, PHS, NAIHS, SHIPROCK HOSPITAL
Entity Type:Organization
Organization Name:DHHS, PHS, NAIHS, SHIPROCK HOSPITAL
Other - Org Name:FOUR CORNERS REGIONAL HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FANNESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:COMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-368-6005
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420-0160
Mailing Address - Country:US
Mailing Address - Phone:505-368-6401
Mailing Address - Fax:505-368-6431
Practice Address - Street 1:US HWY 160 & NAVAJO ROUTE 35 - RED MESA
Practice Address - Street 2:
Practice Address - City:TEECNOSPOS
Practice Address - State:AZ
Practice Address - Zip Code:86514
Practice Address - Country:US
Practice Address - Phone:505-368-6401
Practice Address - Fax:505-368-6431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ282586Medicaid
UT7000000084Medicaid
UT7000000092Medicaid
NM61109321Medicaid
CO37256718Medicaid
HSZ218Medicare PIN
UT7000000092Medicaid