Provider Demographics
NPI:1942324686
Name:NORTH COUNTRY HEALTHCARE, INC.
Entity Type:Organization
Organization Name:NORTH COUNTRY HEALTHCARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/CMO
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-522-9576
Mailing Address - Street 1:PO BOX 3630
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-3630
Mailing Address - Country:US
Mailing Address - Phone:928-522-9879
Mailing Address - Fax:928-522-9880
Practice Address - Street 1:112 PARK AVENUE
Practice Address - Street 2:
Practice Address - City:ASHFORK
Practice Address - State:AZ
Practice Address - Zip Code:86320
Practice Address - Country:US
Practice Address - Phone:928-637-2305
Practice Address - Fax:928-637-2343
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH COUNTRY HEALTHCARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-19
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261QM1300X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ031829Medicare Oscar/Certification
AZZ20283Medicare PIN
AZ031829Medicare Oscar/Certification
AZOTC1363OtherOUTPATIENT TREATMENT CENTER