Common Contracts
1 similar Provider Agreement contracts
ARIZONA VACCINES FOR CHILDREN (VFC) PROGRAM 2017 PROVIDER AGREEMENTProvider Agreement • January 28th, 2022
FACILITY INFORMATIONFacility Name: MOHAVE CHD-BULLHEAD CITY VFC Pin#: 0009B Facility Address: 1222 HANCOCK RD City: BULLHEAD CITY County: MOHAVE State: AZ Zip: 86442 Telephone: (928)753-0714 Fax: (928)753-0775 Shipping Address(if different than facility address): 1222 HANCOCK RD City: BULLHEAD CITY County: MOHAVEMEDICAL DIRECTOR OR EQUIVALENT State: AZ Zip: 86442 Instructions: The official VFC registered health care provider signing the agreement must be a practitioner authorized to administer pediatric vaccines under state law who will also be held accountable for compliance by the entire organization and its VFC providers with the responsible conditions outlined in the provider enrollment agreement. The individual listed here must sign the provider agreement. Last Name, First, MI: NGUYEN, DAT, Title:MD Specialty: License No.: 36837 Medicaid or NPI No.: 1982698528 Employer Identification No.:(optional): Provide Information for second individual as needed: Last Name, First, MI: Ti
