Provider Demographics
NPI:1679757819
Name:NORTHERN APACHE COUNTY SPECIAL HEALTH CARE DISTRICT
Entity Type:Organization
Organization Name:NORTHERN APACHE COUNTY SPECIAL HEALTH CARE DISTRICT
Other - Org Name:ST. MICHAELS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-810-3814
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:SAINT MICHAELS
Mailing Address - State:AZ
Mailing Address - Zip Code:86511-0370
Mailing Address - Country:US
Mailing Address - Phone:928-810-3814
Mailing Address - Fax:928-810-3811
Practice Address - Street 1:359 WEST HIGHWAY 264
Practice Address - Street 2:SUITE A
Practice Address - City:SAINT MICHAELS
Practice Address - State:AZ
Practice Address - Zip Code:86511
Practice Address - Country:US
Practice Address - Phone:928-810-3800
Practice Address - Fax:928-810-3801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC2967207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ709248Medicaid
NM68357303Medicaid