1609967645 NPI number — DESERT ROSE MANAGEMENT CORP

Table of content: (NPI 1609967645)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609967645 NPI number — DESERT ROSE MANAGEMENT CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESERT ROSE MANAGEMENT CORP
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:
DESERT ROSE IMAGING CENTER
Provider Other Organization Name Type Code:
3
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:
1609967645
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5800 NW PRAIRIE VIEW RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KANSAS CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64151-2764
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-587-1818
Provider Business Mailing Address Fax Number:
816-505-5004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1708 SYCAMORE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGMAN
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86401-0927
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-681-3600
Provider Business Practice Location Address Fax Number:
928-681-3612
Provider Enumeration Date:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ASHER
Authorized Official First Name:
PAMELA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
816-587-1818

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X , with the licence number:  OTC 3365 , 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: 763707 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: AZ0728540 . This is a "BCBS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 763707 . This is a "AHCCCS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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