Provider Demographics
NPI:1700867819
Name:GILA RIVER HEALTHCARE CORPORATION
Entity Type:Organization
Organization Name:GILA RIVER HEALTHCARE CORPORATION
Other - Org Name:GILA RIVER DIALYSIS WEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERMIN ADMINSTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-271-7901
Mailing Address - Street 1:PO BOX 2176
Mailing Address - Street 2:
Mailing Address - City:SACATON
Mailing Address - State:AZ
Mailing Address - Zip Code:85247-2176
Mailing Address - Country:US
Mailing Address - Phone:602-271-7901
Mailing Address - Fax:602-271-7970
Practice Address - Street 1:9721 W. PECOS ROAD
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339
Practice Address - Country:US
Practice Address - Phone:602-271-7950
Practice Address - Fax:602-271-7976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ033503Medicare ID - Type Unspecified