1376601914 NPI number — SEQUELCARE OF ARIZONA, LLC

Table of content: (NPI 1376601914)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376601914 NPI number — SEQUELCARE OF ARIZONA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SEQUELCARE OF ARIZONA, LLC
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:
PRESCOTT OPC
Provider Other Organization Name Type Code:
5
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:
1376601914
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3170 STILLWATER DR.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRESCOTT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-777-3280
Provider Business Mailing Address Fax Number:
928-717-1660

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3170 STILLWATER DR.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRESCOTT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-777-3280
Provider Business Practice Location Address Fax Number:
928-717-1660
Provider Enumeration Date:
12/05/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RAZO
Authorized Official First Name:
WENDY
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
928-777-3280

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  BH-2730 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: BH-3517 , 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: 451604 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 157612 . This is a "AHCCCS ID" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".