Provider Demographics
NPI:1215083951
Name:DHHS PHS NAIHS SHIPROCK HOSPITAL
Entity type:Organization
Organization Name:DHHS PHS NAIHS SHIPROCK HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FANNESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:COMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-368-6001
Mailing Address - Street 1:HCR 61 BOX 30
Mailing Address - Street 2:
Mailing Address - City:TEECNOSPOS
Mailing Address - State:AZ
Mailing Address - Zip Code:86514
Mailing Address - Country:US
Mailing Address - Phone:928-656-5000
Mailing Address - Fax:928-656-5164
Practice Address - Street 1:US HWY 160 & NAVAJO ROUTE 35 - RED MESA
Practice Address - Street 2:
Practice Address - City:TEECNOSPOS
Practice Address - State:AZ
Practice Address - Zip Code:86514
Practice Address - Country:US
Practice Address - Phone:928-656-5000
Practice Address - Fax:505-656-5164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ183669Medicaid
NM61109321Medicaid
AZ282586Medicaid
CO37256718Medicaid
UT7000000084Medicaid
UT7000000092Medicaid
AZ282586Medicaid
HSZ218Medicare PIN
AZ183669Medicaid