Provider Demographics
NPI:1699854430
Name:CATHOLIC COMMUNITY SERVICES OF SO AZ INC.
Entity Type:Organization
Organization Name:CATHOLIC COMMUNITY SERVICES OF SO AZ INC.
Other - Org Name:ST ELIZABETH OF HUNGARY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:520-628-7871
Mailing Address - Street 1:140 W SPEEDWAY BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85705-7687
Mailing Address - Country:US
Mailing Address - Phone:520-628-7871
Mailing Address - Fax:520-205-8461
Practice Address - Street 1:140 W SPEEDWAY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-7687
Practice Address - Country:US
Practice Address - Phone:520-628-7871
Practice Address - Fax:520-205-8461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC0037261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ062125Medicaid
AZ105766Medicare PIN