Provider Demographics
NPI:1598292377
Name:WHITE MOUNTAIN REGIONAL MEDICAL CENTER RURAL HEALTH CLINIC
Entity Type:Organization
Organization Name:WHITE MOUNTAIN REGIONAL MEDICAL CENTER RURAL HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN-BC
Authorized Official - Phone:928-333-7173
Mailing Address - Street 1:118 S MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGERVILLE
Mailing Address - State:AZ
Mailing Address - Zip Code:85938-5104
Mailing Address - Country:US
Mailing Address - Phone:928-333-7173
Mailing Address - Fax:928-333-7157
Practice Address - Street 1:114 S MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:SPRINGERVILLE
Practice Address - State:AZ
Practice Address - Zip Code:85938-5104
Practice Address - Country:US
Practice Address - Phone:928-333-7173
Practice Address - Fax:928-333-7157
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WHITE MOUNTAIN REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-05-11
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH2530261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center