Provider Demographics
NPI:1790953214
Name:DHHS PHS NAIHS FORT DEFIANCE HOSPITAL
Entity Type:Organization
Organization Name:DHHS PHS NAIHS FORT DEFIANCE HOSPITAL
Other - Org Name:PHS FORT DEFIANCE INDIAN HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANKLIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:FREELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-729-8014
Mailing Address - Street 1:PO BOX 649
Mailing Address - Street 2:CORNER OF ROUTE N12 & N7
Mailing Address - City:FORT DEFIANCE
Mailing Address - State:AZ
Mailing Address - Zip Code:86504-0649
Mailing Address - Country:US
Mailing Address - Phone:928-729-8014
Mailing Address - Fax:928-729-8158
Practice Address - Street 1:CORNER OF ROUTE N12 & N7
Practice Address - Street 2:
Practice Address - City:FORT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504
Practice Address - Country:US
Practice Address - Phone:928-729-8003
Practice Address - Fax:928-729-8158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ282N00000X261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH0010Medicaid
AZ417982Medicaid
AC0017Medicare PIN