Provider Demographics
NPI:1629041546
Name:GOVERNMENT OF GUAM DEPARTMENT OF ADMINISTRATION
Entity Type:Organization
Organization Name:GOVERNMENT OF GUAM DEPARTMENT OF ADMINISTRATION
Other - Org Name:SOUTHERN REGION COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:UNPINGCO
Authorized Official - Last Name:DENORCEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:671-635-4422
Mailing Address - Street 1:162 ABMAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:INARAJAN
Mailing Address - State:GU
Mailing Address - Zip Code:96915-2816
Mailing Address - Country:US
Mailing Address - Phone:671-828-7501
Mailing Address - Fax:671-828-7504
Practice Address - Street 1:162 ABMAN DRIVE
Practice Address - Street 2:
Practice Address - City:INARAJAN
Practice Address - State:GU
Practice Address - Zip Code:96915-2816
Practice Address - Country:US
Practice Address - Phone:671-828-7501
Practice Address - Fax:671-828-7504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-10
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GU261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GUOTH000Medicare UPIN
GU65-1800Medicare ID - Type UnspecifiedFQHC