Provider Demographics
NPI:1104980911
Name:GILA RIVER HEALTH CARE CORPORATION DME
Entity type:Organization
Organization Name:GILA RIVER HEALTH CARE CORPORATION DME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:
Authorized Official - First Name:LOREN
Authorized Official - Middle Name:P
Authorized Official - Last Name:ELLORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-528-1431
Mailing Address - Street 1:483 W. SEED FARM ROAD
Mailing Address - Street 2:P. O. BOX 38
Mailing Address - City:SACATON
Mailing Address - State:AZ
Mailing Address - Zip Code:85247
Mailing Address - Country:US
Mailing Address - Phone:888-484-8526
Mailing Address - Fax:602-528-1245
Practice Address - Street 1:483 WEST SEED FARM RD
Practice Address - Street 2:GILA RIVER HEALTH CARE CORPORATION
Practice Address - City:SACATON
Practice Address - State:AZ
Practice Address - Zip Code:85247-0038
Practice Address - Country:US
Practice Address - Phone:888-484-8526
Practice Address - Fax:602-528-1245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ07-488076N332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1096330001Medicare NSC