Provider Demographics
NPI:1518957398
Name:NAVAJO HEALTH FOUNDATION-SAGE MEMORIAL HOSPITAL INC
Entity Type:Organization
Organization Name:NAVAJO HEALTH FOUNDATION-SAGE MEMORIAL HOSPITAL INC
Other - Org Name:SAGE MEMORIAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL EXECUTIVE PROJECT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CORONEL
Authorized Official - Middle Name:EINNA-ERNEST
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:269-861-4630
Mailing Address - Street 1:PO BOX 457
Mailing Address - Street 2:
Mailing Address - City:GANADO
Mailing Address - State:AZ
Mailing Address - Zip Code:86505-0457
Mailing Address - Country:US
Mailing Address - Phone:928-755-4500
Mailing Address - Fax:
Practice Address - Street 1:US 191 & AZ 264
Practice Address - Street 2:
Practice Address - City:GANADO
Practice Address - State:AZ
Practice Address - Zip Code:86505
Practice Address - Country:US
Practice Address - Phone:928-755-4500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRGH3899261QC0050X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC0050XAmbulatory Health Care FacilitiesClinic/CenterCritical Access Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM68634277Medicaid
AZ021353Medicaid
AZ1447315494OtherPHARMACY
AZ1447315494OtherPHARMACY
NM68634277Medicaid
AZ03Z309Medicare Oscar/Certification