Provider Demographics
NPI:1003213828
Name:COBRE VALLEY REGIONAL MEDICAL CENTER
Entity type:Organization
Organization Name:COBRE VALLEY REGIONAL MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:NEAL
Authorized Official - Middle Name:D
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-402-1122
Mailing Address - Street 1:5880 S HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:GLOBE
Mailing Address - State:AZ
Mailing Address - Zip Code:85501-9447
Mailing Address - Country:US
Mailing Address - Phone:928-425-3261
Mailing Address - Fax:928-425-3859
Practice Address - Street 1:5880 S HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:GLOBE
Practice Address - State:AZ
Practice Address - Zip Code:85501-9447
Practice Address - Country:US
Practice Address - Phone:928-425-3261
Practice Address - Fax:928-425-3859
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COBRE VALLEY REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-21
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH0126291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ020644Medicaid
AZ020644Medicaid