Provider Demographics
NPI:1427101377
Name:PHOENIX INDIAN MEDICAL CENTER
Entity type:Organization
Organization Name:PHOENIX INDIAN MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PUBLIC HEALTH NURSE
Authorized Official - Prefix:MR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:602-248-4194
Mailing Address - Street 1:1244 E BETHANY HOME RD
Mailing Address - Street 2:36-A
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2043
Mailing Address - Country:US
Mailing Address - Phone:602-266-2281
Mailing Address - Fax:
Practice Address - Street 1:4212 N 16TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5319
Practice Address - Country:US
Practice Address - Phone:602-248-4194
Practice Address - Fax:602-200-5381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN051810163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity HealthGroup - Multi-Specialty