Provider Demographics
NPI:1609245273
Name:INTERMOUNTAIN HEALTH CENTER INC
Entity Type:Organization
Organization Name:INTERMOUNTAIN HEALTH CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:520-721-1887
Mailing Address - Street 1:PO BOX 86537
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85754-6537
Mailing Address - Country:US
Mailing Address - Phone:520-721-1887
Mailing Address - Fax:520-721-0069
Practice Address - Street 1:5055 E BROADWAY BLVD STE C104
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-3641
Practice Address - Country:US
Practice Address - Phone:520-628-9833
Practice Address - Fax:520-623-9083
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTERMOUNTAIN CENTERS FOR HUMAN DEVELOPMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-24
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZOTC7779OtherADHS/BMFL LICENSE
AZ198509Medicaid