Provider Demographics
NPI:1811468804
Name:SUMMIT HEALTHCARE ASSOCIATION
Entity type:Organization
Organization Name:SUMMIT HEALTHCARE ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF NURSING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:B
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-537-6932
Mailing Address - Street 1:2200 E. SHOW LOW LAKE ROAD
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901
Mailing Address - Country:US
Mailing Address - Phone:928-537-6321
Mailing Address - Fax:928-537-7814
Practice Address - Street 1:4951 SOUTH WHITE MOUNTAIN ROAD, BLDG A., SUITE 1500
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901
Practice Address - Country:US
Practice Address - Phone:928-537-6336
Practice Address - Fax:928-532-3506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-17
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ470811Medicaid