Provider Demographics
NPI:1700060878
Name:GILA RIVER INDIAN COMMUNITY DEPARTMENT OF HUMAN SERVICES
Entity Type:Organization
Organization Name:GILA RIVER INDIAN COMMUNITY DEPARTMENT OF HUMAN SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACTING DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:CUMMINGS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:520-562-3356
Mailing Address - Street 1:PO BOX 2171
Mailing Address - Street 2:
Mailing Address - City:SACATON
Mailing Address - State:AZ
Mailing Address - Zip Code:85247-2171
Mailing Address - Country:US
Mailing Address - Phone:520-562-3356
Mailing Address - Fax:
Practice Address - Street 1:315 W. CASA BLANCA RD
Practice Address - Street 2:
Practice Address - City:SACATON
Practice Address - State:AZ
Practice Address - Zip Code:85247-2171
Practice Address - Country:US
Practice Address - Phone:520-562-3356
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ074165OtherAHCCCS