Provider Demographics
NPI:1619207370
Name:PASCUA YAQUI TRIBE
Entity Type:Organization
Organization Name:PASCUA YAQUI TRIBE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-879-6163
Mailing Address - Street 1:9405 S AVENIDA DEL YAQUI
Mailing Address - Street 2:
Mailing Address - City:GUADALUPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-2529
Mailing Address - Country:US
Mailing Address - Phone:480-768-2000
Mailing Address - Fax:480-768-2053
Practice Address - Street 1:9405 S AVENIDA DEL YAQUI
Practice Address - Street 2:
Practice Address - City:GUADALUPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-2529
Practice Address - Country:US
Practice Address - Phone:480-768-2000
Practice Address - Fax:480-768-2053
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PYT GUADALUPE SEWA UUSIM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-31
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2283251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2283Medicaid