Provider Demographics
NPI:1659337848
Name:MT GRAHAM REGIONAL MEDICAL CENTER INC
Entity Type:Organization
Organization Name:MT GRAHAM REGIONAL MEDICAL CENTER INC
Other - Org Name:MT GRAHAM HOME HEALTH
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:DENICE
Authorized Official - Last Name:HEINRICH
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN
Authorized Official - Phone:928-428-5668
Mailing Address - Street 1:1600 S. 20TH AVE., BLDG. E
Mailing Address - Street 2:
Mailing Address - City:SAFFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85546
Mailing Address - Country:US
Mailing Address - Phone:928-428-5668
Mailing Address - Fax:928-348-3868
Practice Address - Street 1:1600 S. 20TH AVE., BLDG. E
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546
Practice Address - Country:US
Practice Address - Phone:928-428-5668
Practice Address - Fax:928-348-3868
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MT GRAHAM REGIONAL MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-25
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZHHA-210251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZHHA-210OtherADHS NUMBER
AZ03D0886073OtherCLIA NUMBER
AZ317786Medicaid
AZ037312Medicare ID - Type Unspecified