Provider Demographics
NPI:1497985196
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:Doing Business As
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:505-368-6001
Mailing Address - Street 1:HCR 6100, BOX 30
Mailing Address - Street 2:
Mailing Address - City:TEECNOSPOS
Mailing Address - State:AZ
Mailing Address - Zip Code:86514
Mailing Address - Country:US
Mailing Address - Phone:928-656-5000
Mailing Address - Fax:928-656-5164
Practice Address - Street 1:US HWY 160 & NAVAJO ROUTE 25 - 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:928-656-5000
Practice Address - Fax:928-656-5164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-16
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
320059Medicare Oscar/Certification