Provider Demographics
NPI:1922547223
Name:TUBA CITY REGIONAL HEALTH CARE CORPORATION
Entity Type:Organization
Organization Name:TUBA CITY REGIONAL HEALTH CARE CORPORATION
Other - Org Name:HEALTHY LIVING CENTER/DIABETES TREATMENT & PREVENTION SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LYNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BONAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-283-2501
Mailing Address - Street 1:PO BOX 600
Mailing Address - Street 2:
Mailing Address - City:TUBA CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86045-0600
Mailing Address - Country:US
Mailing Address - Phone:928-283-2094
Mailing Address - Fax:928-283-2677
Practice Address - Street 1:167 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:TUBA CITY
Practice Address - State:AZ
Practice Address - Zip Code:86045
Practice Address - Country:US
Practice Address - Phone:928-283-2094
Practice Address - Fax:928-283-2677
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TUBA CITY REGIONAL HEALTH CARE CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ200013133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ721250Medicaid