Provider Demographics
NPI:1770753543
Name:CHINLE NURSING HOME
Entity type:Organization
Organization Name:CHINLE NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-674-5216
Mailing Address - Street 1:PO BOX 910
Mailing Address - Street 2:
Mailing Address - City:CHINLE
Mailing Address - State:AZ
Mailing Address - Zip Code:86503-0910
Mailing Address - Country:US
Mailing Address - Phone:928-674-5216
Mailing Address - Fax:928-674-5218
Practice Address - Street 1:HWY 191 N HOSP RD
Practice Address - Street 2:
Practice Address - City:CHINLE
Practice Address - State:AZ
Practice Address - Zip Code:86503
Practice Address - Country:US
Practice Address - Phone:928-674-5216
Practice Address - Fax:928-674-5218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35242311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ=========Medicaid