Provider Demographics
NPI:1639519002
Name:MATERNAL CHILD HEALTH PROGRAM
Entity Type:Organization
Organization Name:MATERNAL CHILD HEALTH PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRIBAL CHAIRMAN
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:RAMBLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-475-2361
Mailing Address - Street 1:P.O. BOX 0
Mailing Address - Street 2:BUILDING 15, SAN CARLOS AV
Mailing Address - City:SAN CARLOS
Mailing Address - State:AZ
Mailing Address - Zip Code:85550-9999
Mailing Address - Country:US
Mailing Address - Phone:928-475-2798
Mailing Address - Fax:
Practice Address - Street 1:BULDING 15, SAN CARLOS AVE
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:AZ
Practice Address - Zip Code:85550-9999
Practice Address - Country:US
Practice Address - Phone:928-475-2798
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAN CARLOS APACHE TRIBE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-07-01
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care