Provider Demographics
NPI:1871739755
Name:SACRED MOUNTAIN MEDICAL SERVICE
Entity type:Organization
Organization Name:SACRED MOUNTAIN MEDICAL SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:
Authorized Official - Last Name:BARNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-283-8243
Mailing Address - Street 1:PO BOX 2290
Mailing Address - Street 2:
Mailing Address - City:TUBA CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86045-2290
Mailing Address - Country:US
Mailing Address - Phone:928-283-8243
Mailing Address - Fax:928-283-8237
Practice Address - Street 1:100 MOENAVE ROAD
Practice Address - Street 2:#39
Practice Address - City:TUBA CITY
Practice Address - State:AZ
Practice Address - Zip Code:86045
Practice Address - Country:US
Practice Address - Phone:928-283-8243
Practice Address - Fax:928-283-8237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-26
Last Update Date:2008-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1273416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM40953866Medicaid
CAXMTEO6557Medicaid
AZ717077Medicaid
AZAZ0152480OtherBLUE CROSS BLUE SHIELD
MS02876271Medicaid
UT830384848001Medicaid
AZ717077Medicaid
AZZ77633Medicare PIN