Provider Demographics
NPI:1053418533
Name:FORT MCDOWELL YAVAPAI NATION
Entity type:Organization
Organization Name:FORT MCDOWELL YAVAPAI NATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEMETRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BARR REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-816-7199
Mailing Address - Street 1:PO BOX 17779
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85269-7779
Mailing Address - Country:US
Mailing Address - Phone:480-789-7890
Mailing Address - Fax:480-789-7894
Practice Address - Street 1:16240 NORTH FORT MCDOWELL
Practice Address - Street 2:
Practice Address - City:FORT MCDOWELL
Practice Address - State:AZ
Practice Address - Zip Code:85264-3402
Practice Address - Country:US
Practice Address - Phone:480-789-7890
Practice Address - Fax:480-789-7894
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FORT MCDOWELL YAVAPAI NATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-19
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ75856Medicare PIN