1891088803 NPI number — DESERT SKY FAMILY CLINIC OF YUMA

Table of content: (NPI 1891088803)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891088803 NPI number — DESERT SKY FAMILY CLINIC OF YUMA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESERT SKY FAMILY CLINIC OF YUMA
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:
Provider Other Organization Name Type Code:
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:
1891088803
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2180 S 4TH AVE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
YUMA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85364-6478
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-783-0919
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2180 S 4TH AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
YUMA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85364-6478
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-783-0919
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/24/2011

Additional Information

Authorized Official

Authorized Official Last Name:
RIVERA
Authorized Official First Name:
ANA
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
FAMILY NURSE PRACTITIONER
Authorized Official Telephone Number:
928-783-0919

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP 1944 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: AP 3602 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: NPI 1720138415 . This is a "NATIONAL PROVIDER IDENTIFIER" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: NPI 1992013122 . This is a "NATIONAL PROVIDER IDENFIFICATION" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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