Provider Demographics
NPI:1912921677
Name:DHEW IND HLTH SV HLTH SVS & MNTL HLTH
Entity Type:Organization
Organization Name:DHEW IND HLTH SV HLTH SVS & MNTL HLTH
Other - Org Name:GILA BEND CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:(CEO) CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MISS
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:DICK
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, MHA
Authorized Official - Phone:602-263-1567
Mailing Address - Street 1:PO BOX 31001-0698
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-0698
Mailing Address - Country:US
Mailing Address - Phone:602-263-1200
Mailing Address - Fax:602-263-1618
Practice Address - Street 1:100 NORTH GILA BOULVARD
Practice Address - Street 2:
Practice Address - City:GILA BEND
Practice Address - State:AZ
Practice Address - Zip Code:85337-2658
Practice Address - Country:US
Practice Address - Phone:602-263-1200
Practice Address - Fax:602-263-1618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ812851Medicaid
AZ030078Medicare Oscar/Certification
AZ812851Medicaid