A3 W. Debarments.pdf

CONTRACT AMENDMENT

ARIZONA DEPARTMENT OF

HEALTH SERVICES

OFFICE OF PROCUREMENT

150 N 18th Ave., Ste. #530 Phoenix, Arizona 85007

CONTRACT NO.: CTR050598 AMENDMENT NO.: THREE (3) PROCUREMENT OFFICER

PAUL EVANS

Effective upon signature by both parties, it is mutually agreed that the Contract referenced in this Amendment Three (3) is amended as follows:

1. Pursuant to the Special Terms and Conditions, Provision Three (3), Contract Extensions Five (5) Year Maximum, the Contract is extended for the fourth (4th) year through July 5, 2024.

ALL OTHER PROVISIONS SHALL REMAIN IN THEIR ENTIRETY

Contractor hereby acknowledges receipt and acceptance of above amendment and that a signed copy must be filed with the Procurement Office before the effective date

The above referenced Contract Amendment is hereby executed this _____ day of __________ 20______ at Phoenix, Arizona

(To be filled out by Procurement Office)

Contractor Signature

Contractor Signature Date

Authorized Signatory’s Name and Title

Native Health, Inc.

Contractor’s Name Procurement Officer Signature

6/29/2023

Walter Murillo, CEO Paul Evans Digitally signed by Paul Evans Date: 2023.06.30 19:52:48 -07'00'

8/30/23, 11:22 AM Arizona Corporations Commission https://ecorp.azcc.gov/BusinessSearch/BusinessInfo?entityNumber=01177286 1/2

ENTITY INFORMATION

Search Date and Time: 8/30/2023 11:22:28 AM

Title Name Attention Address Date of Taking Office

Last Updated

CEO (Chief Executive Officer)

WALTER

MURILLO

4041 N CENTRAL AVE, BLDG C,

PHOENIX, AZ, 85012, Maricopa County, USA

9/30/2000 2/1/2019

Entity Details

Entity Name: NATIVE HEALTH Entity ID: 01177286

Entity Type: Domestic Nonprofit Corporation Entity Status: Active

Formation Date: 8/31/1978 Reason for Status: In Good Standing

Approval Date: 8/31/1978 Status Date:

Original Incorporation Date:

8/31/1978 Life Period: Perpetual

Business Type: Other - NATIVE HEALTH Last Annual Report Filed: 2023

Domicile State: Arizona Annual Report Due Date: 1/31/2024

Years Due:

Original Publish Date: 9/19/1978

Statutory Agent Information

Name: WALTER MURILLO Appointed Status: Active

Attention:

Address: 4041 N CENTRAL AVE BLDG C , PHOENIX, AZ 85012, USA

Agent Last Updated: 12/28/2022 E-mail:

Attention: Mailing Address:

County: Maricopa

Principal Information

Privacy Policy (http://azcc.gov/privacy-policy) ǀ Contact Us (http://azcc.gov/corporations/corporation-contacts) http://azcc.gov/privacy-policy http://azcc.gov/corporations/corporation-contacts

8/30/23, 11:22 AM Arizona Corporations Commission https://ecorp.azcc.gov/BusinessSearch/BusinessInfo?entityNumber=01177286 2/2

Page 1 of 1, records 1 to 4 of 4

Title Name Attention Address Date of Taking Office

Last Updated

Director Jeanine Edaakie

4041 N CENTRAL AVE, BLDG C,

PHOENIX, AZ, 85012, Maricopa County, USA

6/20/2017 1/4/2022

CFO (Chief Financial Officer)

Cody Nelson

4041 N CENTRAL AVE BLDG C,

PHOENIX, AZ, 85012, Maricopa County, USA

7/6/2018 2/1/2019

Treasurer Brianna Jagelski

4041 N CENTRAL AVE BLDG C,

PHOENIX, AZ, 85012, Maricopa County, USA

8/1/2015 1/4/2022

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Document History Name/Restructuring History

Pending Documents Microfilm History

Address

Attention:

Walter Murillo

Address: 4041 N CENTRAL AVE BLDG C, PHOENIX, AZ, 85012, USA

County:

Maricopa

Last Updated: 12/28/2022

Entity Principal Office Address

Attention: Address: County: Last Updated:

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NATIVE HEALTH

Unique Entity ID

MQGXUX1QMZL8

CAGE / NCAGE

494S5

Purpose of Registration

All Awards

Registration Status

Active Registration

Expiration Date

Dec 6, 2023

Physical Address

4041 N Central AVE Building C

Phoenix, Arizona 85012-3313

United States

Mailing Address

4041 N Central AVE Building C

Phoenix, Arizona 85012-3313

United States

Business Information

Doing Business as

Native American Community Health Center

Division Name

(blank)

Division Number

(blank)

Congressional District

Arizona 09

State / Country of Incorporation

Arizona / United States

URL

(blank)

Registration Dates

Activation Date

Dec 8, 2022

Submission Date

Dec 6, 2022

Initial Registration Date

Jan 5, 2006

Entity Dates

Entity Start Date

Aug 30, 1978

Fiscal Year End Close Date

Sep 30

Immediate Owner

CAGE

(blank)

Legal Business Name

(blank)

Highest Level Owner

CAGE

(blank)

Legal Business Name

(blank)

Executive Compensation

Registrants in the System for Award Management (SAM) respond to the Executive Compensation questions in accordance with Section 6202 of

P.L. 110-252, amending the Federal Funding Accountability and Transparency Act (P.L. 109-282). This information is not displayed in SAM. It is sent to USAspending.gov for display in association with an eligible award. Maintaining an active registration in SAM demonstrates the registrant responded to the questions.

Proceedings Questions

Registrants in the System for Award Management (SAM.gov) respond to proceedings questions in accordance with FAR 52.209-7, FAR 52.209-9, or 2. C.F.R. 200 Appendix XII. Their responses are displayed in the responsibility/qualification section of SAM.gov. Maintaining an active registration in SAM.gov demonstrates the registrant responded to the proceedings questions.

Exclusion Summary

Active Exclusions Records?

No

SAM Search Authorization

I authorize my entity's non-sensitive information to be displayed in SAM public search results:

Yes

Entity Types

Business Types

Entity Structure

Corporate Entity (Tax Exempt)

Entity Type

Business or Organization

Organization Factors

(blank)

Profit Structure

Non-Profit Organization

Last updated by FRANCIE BROWN-SPENCER on Dec 06, 2022 at 04:17 PM NATIVE HEALTH

Aug 30, 2023 06:25:02 PM GMT https://sam.gov/entity/MQGXUX1QMZL8/coreData?status=Active Page 1 of 3

Socio-Economic Types

Minority-Owned Business

Native American Owned

Check the registrant's Reps & Certs, if present, under FAR 52.212-3 or FAR 52.219-1 to determine if the entity is an SBA-certified HUBZone small business concern. Additional small business information may be found in the SBA's Dynamic Small Business Search if the entity completed the

SBA supplemental pages during registration.

Federally Recognized Native American Entity

American Indian Owned

Financial Information

Accepts Credit Card Payments

Yes

Debt Subject To Offset

No

EFT Indicator

CAGE Code

494S5

Points of Contact

Electronic Business

Deanna Sangster, COO 4041 N Central Avenue

Building C

Phoenix, Arizona 85012

United States

WALTER Murillo 4041 N Central Avenue Building C

Building C

Phoenix, Arizona 85012

United States

Government Business

WALTER Murillo, CEO 4041 N Central Avenue

Building C

Phoenix, Arizona 85012

United States

Cody Nelson 4041 N Central Avenue Building C

Phoenix, Arizona 85012

United States

Past Performance

Deanna Sangster 4041 N Central Avenue Building C

Phoenix, Arizona 85012

United States

Francie Spencer 4041 N Central Avenue

Building C

Phoenix, Arizona 85012

United States

Service Classifications

NAICS Codes

Primary

Yes

NAICS Codes

621111

NAICS Title

Offices Of Physicians (Except Mental Health Specialists)

621210 Offices Of Dentists

621330 Offices Of Mental Health Practitioners (Except Physicians)

621420 Outpatient Mental Health And Substance Abuse Centers

Disaster Response

Yes, this entity appears in the disaster response registry.

No, this entity does not require bonding to bid on contracts.

Bonding Levels Dollars

Last updated by FRANCIE BROWN-SPENCER on Dec 06, 2022 at 04:17 PM NATIVE HEALTH https://sam.gov/entity/MQGXUX1QMZL8/coreData?status=Active Page 2 of 3

(blank)

States

Arizona

Counties

AZ: Maricopa

Metropolitan Statistical Areas

(blank)

Last updated by FRANCIE BROWN-SPENCER on Dec 06, 2022 at 04:17 PM NATIVE HEALTH https://sam.gov/entity/MQGXUX1QMZL8/coreData?status=Active Page 3 of 3

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NATIVE AMERICAN COMMUNITY HEALTH CENTER

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8/30/23, 11:22 AM Search Results - Arizona Secretary of State https://apps.azsos.gov/apps/tntp/rd.html 1/2

Result Detail Back

File ID: 9111025

Name: Native American Community Health Center

Business Address:

4041 N CENTRAL AVE BLDG C

PHOENIX, Arizona 85012

Mailing Address:

4041 N CENTRAL AVE BLDG C

PHOENIX, Arizona 85012

Phone: 602-279-5262

Nature of Business:

Community health and wellness services

Date of First Use:

August 20, 1996

Date Registered:

June 10, 2019

Expiration Date:

June 10, 2024

Applicants:

NATIVE HEALTH Arizona Corporation

Registration Information:

Registration Received:

June 10, Expires: June 10, (https://azsos.gov/)

(https://azsos.gov/webform/contact-azsos)

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Correspondence History:

Trade Name Application:

Filed: June 10, 2019

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