Provider Demographics
NPI:1760522155
Name:WHITE MOUNTAIN APACHE TRIBE
Entity Type:Organization
Organization Name:WHITE MOUNTAIN APACHE TRIBE
Other - Org Name:WHITE MOUNTAIN APACHE TRIBE EMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EMS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ED
Authorized Official - Middle Name:
Authorized Official - Last Name:BENALLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-338-3095
Mailing Address - Street 1:PO BOX 1210
Mailing Address - Street 2:
Mailing Address - City:WHITERIVER
Mailing Address - State:AZ
Mailing Address - Zip Code:85941-1210
Mailing Address - Country:US
Mailing Address - Phone:928-338-3095
Mailing Address - Fax:928-338-3097
Practice Address - Street 1:103 W. RAINBOW
Practice Address - Street 2:
Practice Address - City:WHITERIVER
Practice Address - State:AZ
Practice Address - Zip Code:85941-1210
Practice Address - Country:US
Practice Address - Phone:928-338-3095
Practice Address - Fax:928-338-3097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ071184Medicaid
Z0000RFBFQMedicare PIN