1134491210 NPI number — ULTIMATE INTEGRATED PATIENT CARE PLLC

Table of content: (NPI 1134491210)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134491210 NPI number — ULTIMATE INTEGRATED PATIENT CARE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ULTIMATE INTEGRATED PATIENT CARE PLLC
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:
1134491210
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10214
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85318-0214
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-718-5986
Provider Business Mailing Address Fax Number:
480-664-6813

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13714 N PLAZA DEL RIO BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85381-4874
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-718-5986
Provider Business Practice Location Address Fax Number:
480-664-6813
Provider Enumeration Date:
02/03/2012

Additional Information

Authorized Official

Authorized Official Last Name:
LOMAN
Authorized Official First Name:
VALARIE
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
480-718-5986

Provider Taxonomy Codes

  • Taxonomy code: 311Z00000X , with the licence number:  005286 , 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: 456982 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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