Provider Demographics
NPI:1497021844
Name:COBRE VALLEY REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:COBRE VALLEY REGIONAL MEDICAL CENTER
Other - Org Name:PLEASANT VALLEY COMMUNITY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NEAL
Authorized Official - Middle Name:D
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-425-3261
Mailing Address - Street 1:PO BOX 177
Mailing Address - Street 2:
Mailing Address - City:YOUNG
Mailing Address - State:AZ
Mailing Address - Zip Code:85554-0000
Mailing Address - Country:US
Mailing Address - Phone:928-462-3435
Mailing Address - Fax:928-462-6644
Practice Address - Street 1:124 N TEWSKBURY BLVD
Practice Address - Street 2:
Practice Address - City:YOUNG
Practice Address - State:AZ
Practice Address - Zip Code:85554-0000
Practice Address - Country:US
Practice Address - Phone:928-462-3435
Practice Address - Fax:928-462-6644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-30
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH0126261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ371306Medicaid
AZ371306Medicaid