Provider Demographics
NPI:1366993636
Name:FORT DEFIANCE INDIAN HOSPITAL BOARD, INC
Entity type:Organization
Organization Name:FORT DEFIANCE INDIAN HOSPITAL BOARD, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:ARINTINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-729-8902
Mailing Address - Street 1:P.O. BOX 589
Mailing Address - Street 2:FORT DEFIANCE INDIAN HOSPITAL BOARD, INC.
Mailing Address - City:FORT DEFIANCE
Mailing Address - State:AZ
Mailing Address - Zip Code:86504
Mailing Address - Country:US
Mailing Address - Phone:928-279-8000
Mailing Address - Fax:
Practice Address - Street 1:CORNER OF ROUTE N12 AND N7
Practice Address - Street 2:FORT DEFIANCE INDIAN HOSPITAL BOARD, INC
Practice Address - City:FORT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504-0589
Practice Address - Country:US
Practice Address - Phone:928-279-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2012-0766282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1982915443Medicaid