1205160355 NPI number — CENTRO MEDICO DEL VALLE PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205160355 NPI number — CENTRO MEDICO DEL VALLE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRO MEDICO DEL VALLE PC
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:
1205160355
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2929 N 75TH AVE
Provider Second Line Business Mailing Address:
SUITE 5
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85033-5400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-873-1200
Provider Business Mailing Address Fax Number:
623-873-1300

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2929 N 75TH AVE
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85033-5400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-873-1200
Provider Business Practice Location Address Fax Number:
623-873-1300
Provider Enumeration Date:
09/22/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LOPEZ
Authorized Official First Name:
ENRIQUE
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
623-873-1200

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  35764 , 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: 462677 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".