Provider Demographics
NPI:1316104573
Name:MARANA HEALTH CENTER, INC
Entity type:Organization
Organization Name:MARANA HEALTH CENTER, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:
Authorized Official - Last Name:KUNTZ
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:520-682-4111
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85653-0188
Mailing Address - Country:US
Mailing Address - Phone:520-682-4111
Mailing Address - Fax:520-818-3630
Practice Address - Street 1:2202 W ANKLAM RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85709-0001
Practice Address - Country:US
Practice Address - Phone:520-616-6790
Practice Address - Fax:520-622-0849
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARANA HEALTH CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-16
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOCT4381261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ928895Medicaid
AZ329592OtherAHCCCS GROUP NUMBER
AZZWMBRVMedicare PIN
AZ031874Medicare Oscar/Certification