1962736348 NPI number — FAMILY MEDICINE & WEIGHT MANAGEMENT SPECIALTY, P.L.L.C.

Table of content: (NPI 1962736348)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962736348 NPI number — FAMILY MEDICINE & WEIGHT MANAGEMENT SPECIALTY, P.L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY MEDICINE & WEIGHT MANAGEMENT SPECIALTY, P.L.L.C.
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:
1962736348
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2189 S. AVENUE A, SUITE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YUMA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85364-8880
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-276-4381
Provider Business Mailing Address Fax Number:
928-276-9086

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2222 S AVENUE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YUMA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85364-8315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-276-4381
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/01/2009

Additional Information

Authorized Official

Authorized Official Last Name:
SORENSEN
Authorized Official First Name:
KIRSTEN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
602-431-1152

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  4158 , 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)

  • Identifier: Z178594 . This is a "MEDICARE PTAN FOR STATEOF ARIZONA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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