1023041654 NPI number — LEVEL 4 MEDICAL PROFESSIONAL CORPORATION

Table of content: (NPI 1023041654)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023041654 NPI number — LEVEL 4 MEDICAL PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEVEL 4 MEDICAL PROFESSIONAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FOOTHILLS WALK-IN MEDICAL AND URGENT CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023041654
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11274 S FORTUNA RD
Provider Second Line Business Mailing Address:
STE I 4
Provider Business Mailing Address City Name:
YUMA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85367-7847
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-345-2150
Provider Business Mailing Address Fax Number:
928-345-2151

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11274 S FORTUNA RD
Provider Second Line Business Practice Location Address:
STE I 4
Provider Business Practice Location Address City Name:
YUMA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85367-7847
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-345-2150
Provider Business Practice Location Address Fax Number:
928-345-2151
Provider Enumeration Date:
07/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SMOCK
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
E
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
928-345-2150

Provider Taxonomy Codes

  • Taxonomy code: 146N00000X , with the licence number:  OTC2699 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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