Provider Demographics
NPI:1720411424
Name:PINAL COUNTY ARIZONA
Entity Type:Organization
Organization Name:PINAL COUNTY ARIZONA
Other - Org Name:PUBLIC HEALTH DEPARTMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:ACCOUNT CLERK-BILLING
Authorized Official - Prefix:
Authorized Official - First Name:SUSIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:ESCALANTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-866-7319
Mailing Address - Street 1:PO BOX 2945
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AZ
Mailing Address - Zip Code:85132-3055
Mailing Address - Country:US
Mailing Address - Phone:520-866-7319
Mailing Address - Fax:520-866-7066
Practice Address - Street 1:110 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MAMMOTH
Practice Address - State:AZ
Practice Address - Zip Code:85618
Practice Address - Country:US
Practice Address - Phone:520-866-7319
Practice Address - Fax:520-866-7066
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PINAL COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-16
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC3524251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ155847Medicaid
AZ155847Medicaid