Provider Demographics
NPI:1740767664
Name:GILA VALLEY CLINIC PC
Entity Type:Organization
Organization Name:GILA VALLEY CLINIC PC
Other - Org Name:GILA VALLEY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:S
Authorized Official - Last Name:COCA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-428-1377
Mailing Address - Street 1:1680 S 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAFFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85546-4011
Mailing Address - Country:US
Mailing Address - Phone:928-428-1377
Mailing Address - Fax:
Practice Address - Street 1:1680 S 20TH AVE
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546
Practice Address - Country:US
Practice Address - Phone:928-428-1377
Practice Address - Fax:928-428-6903
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GILA VALLEY CLINIC PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-24
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ121963Medicaid