Provider Demographics
NPI:1578922787
Name:MARIPOSA COMMUNITY HEALTH CENTER, INC
Entity Type:Organization
Organization Name:MARIPOSA COMMUNITY HEALTH CENTER, INC
Other - Org Name:MARIPOSA TUBAC REGIONAL HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PREVOST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-761-2128
Mailing Address - Street 1:825 N GRAND AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:NOGALES
Mailing Address - State:AZ
Mailing Address - Zip Code:85621-2385
Mailing Address - Country:US
Mailing Address - Phone:520-761-2128
Mailing Address - Fax:520-281-1112
Practice Address - Street 1:2221 E FRONTAGE RD STE 101
Practice Address - Street 2:BLDG G-STE 101/BLDG F-STE 104
Practice Address - City:TUBAC
Practice Address - State:AZ
Practice Address - Zip Code:85646-9997
Practice Address - Country:US
Practice Address - Phone:520-281-1550
Practice Address - Fax:520-281-4487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-16
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4918207Q00000X, 207VG0400X, 208000000X, 208D00000X, 363L00000X
AZ43414207Q00000X, 207VG0400X, 208000000X, 208D00000X
AZ16163207R00000X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ156624Medicaid
AZZFQ31812OtherMEDICARE PART B GROUP#
AZ031938Medicare Oscar/Certification
AZ114872Medicaid