Provider Demographics
NPI:1851651079
Name:COMMUNITY INTERVENTION ASSOCIATES, INC
Entity Type:Organization
Organization Name:COMMUNITY INTERVENTION ASSOCIATES, INC
Other - Org Name:COMMUNITY HEALTH ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:COGBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-376-0026
Mailing Address - Street 1:2851 S. AVE B
Mailing Address - Street 2:BLDG 4
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364
Mailing Address - Country:US
Mailing Address - Phone:928-376-0026
Mailing Address - Fax:928-782-2298
Practice Address - Street 1:2851 S. AVE B
Practice Address - Street 2:SUITE 2901
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364
Practice Address - Country:US
Practice Address - Phone:928-304-7729
Practice Address - Fax:928-344-5577
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY INTERVENTION ASSOCIATES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-22
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X
AZOTC-6468261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ741893Medicaid
AZ741893Medicaid