Common Contracts
1 similar Provider Agreement contracts
ARIZONA VACCINES FOR CHILDREN (VFC) PROGRAM 2017 PROVIDER AGREEMENTProvider Agreement • August 18th, 2020
FACILITY INFORMATIONFacility Name: SUNSET CHC - SOMERTON CLINIC VFC Pin#: 0107 Facility Address: 115 N SOMERTON AVENUE City: SOMERTON County: YUMA State: AZ Zip: 85350 Telephone: (928)627-2051 Fax: (928)627-3857 Shipping Address(if different than facility address): 115 N SOMERTON AVENUE City: SOMERTON County: YUMAMEDICAL DIRECTOR OR EQUIVALENT State: AZ Zip: 85350 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: SOMJEE, SAIKA, Title:MD Specialty: Pediatrics License No.: 36313 Medicaid or NPI No.: 1457429458 Employer Identification No.:(optional): Provide Information for second individual as needed: Last Name,
