Provider Demographics
NPI:1619148772
Name:WHITE MOUNTAIN APACHE
Entity Type:Organization
Organization Name:WHITE MOUNTAIN APACHE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EMMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CROMWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-338-1808
Mailing Address - Street 1:PO BOX 1210
Mailing Address - Street 2:
Mailing Address - City:WHITERIVER
Mailing Address - State:AZ
Mailing Address - Zip Code:85941-1210
Mailing Address - Country:US
Mailing Address - Phone:928-338-1808
Mailing Address - Fax:928-338-5252
Practice Address - Street 1:522 SOUTH FOURTH AVENUE
Practice Address - Street 2:
Practice Address - City:WHITERIVER
Practice Address - State:AZ
Practice Address - Zip Code:85941
Practice Address - Country:US
Practice Address - Phone:928-338-1808
Practice Address - Fax:928-338-5254
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WHITE MOUNTAIN APACHE TRIBE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ044701Medicaid