Provider Demographics
NPI:1962810127
Name:ARCHIE HENDRICKS SR SKILLED NURSING FACILITY
Entity type:Organization
Organization Name:ARCHIE HENDRICKS SR SKILLED NURSING FACILITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO/BUSINESS OFFICE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHASTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-585-5500
Mailing Address - Street 1:HC 1 BOX 9100
Mailing Address - Street 2:
Mailing Address - City:SELLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85634-9744
Mailing Address - Country:US
Mailing Address - Phone:520-585-5500
Mailing Address - Fax:520-585-5510
Practice Address - Street 1:FEDERAL ROUTE 15 MILEPOST 9
Practice Address - Street 2:
Practice Address - City:SELLS
Practice Address - State:AZ
Practice Address - Zip Code:85634-9744
Practice Address - Country:US
Practice Address - Phone:520-585-5500
Practice Address - Fax:520-585-5500
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARCHIE HENDRICKS SR SKILLED NURSING FACILITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-31
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTRIBAL SERVICE261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ035263Medicare Oscar/Certification