| Full Name | |
|---|---|
| Speciality | Clinic/center - Federally Qualified Health Center (fqhc) |
| Location | 110 Main Street, Mammoth, Arizona |
| Authorized Official Name and Position | Travis Robinette (CHIEF EXECUTIVE OFFICER) |
| Authorized Official Contact | 5208363446 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 10097 Casa Grande AZ 85130-0020 Ph: (520) 836-3446 | 110 Main Street Mammoth AZ 85623 Ph: (520) 487-0322 |
| NPI Number | 1184838930 |
|---|---|
| Provider Enumeration Date | 05/10/2007 |
| Last Update Date | 08/03/2017 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1184838930 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | OTC-3754 (Arizona) | Primary |