Provider Demographics
NPI:1700962131
Name:DHHS PHS NAIHS FORT DEFIANCE HOSPITAL
Entity Type:Organization
Organization Name:DHHS PHS NAIHS FORT DEFIANCE HOSPITAL
Other - Org Name:PHS FORT DEFIANCE INDIAN HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANKLIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:FREELAND
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:928-729-8010
Mailing Address - Street 1:PO BOX 649
Mailing Address - Street 2:CORNER OF ROUTE N12 & N7
Mailing Address - City:FORT DEFIANCE
Mailing Address - State:AZ
Mailing Address - Zip Code:86504-0649
Mailing Address - Country:US
Mailing Address - Phone:928-729-8000
Mailing Address - Fax:928-729-8019
Practice Address - Street 1:CORNER OF ROUTE N12 & N7
Practice Address - Street 2:
Practice Address - City:FORT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504-0649
Practice Address - Country:US
Practice Address - Phone:928-729-8000
Practice Address - Fax:928-729-8019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ020488Medicaid
NMH0010Medicaid
030071Medicare Oscar/Certification
NMH0010Medicaid
HSZ165Medicare PIN