Provider Demographics
NPI:1790210755
Name:SALT RIVER PIMA-MARICOPA INDIAN COMMUNITY
Entity Type:Organization
Organization Name:SALT RIVER PIMA-MARICOPA INDIAN COMMUNITY
Other - Org Name:SALT RIVER INTEGRATED HEALTH CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VIOLET
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL-ENOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-362-5480
Mailing Address - Street 1:10005 E OSBORN RD BLDG 61
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85256-4019
Mailing Address - Country:US
Mailing Address - Phone:480-946-9227
Mailing Address - Fax:480-278-7186
Practice Address - Street 1:10005 E OSBORN RD BLDG 61
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85256-4019
Practice Address - Country:US
Practice Address - Phone:480-946-9227
Practice Address - Fax:480-278-7186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-27
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2171598OtherPK
AZ275266Medicaid