1730109232 NPI number — COCHISE SURGICAL CARE PLLC

Table of content: (NPI 1730109232)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730109232 NPI number — COCHISE SURGICAL CARE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COCHISE SURGICAL 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:
1730109232
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
75 COLONIA DE SALUD
Provider Second Line Business Mailing Address:
STE C100
Provider Business Mailing Address City Name:
SIERRA VISTA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85635-2485
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-452-0144
Provider Business Mailing Address Fax Number:
520-452-0075

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 COLONIA DE SALUD
Provider Second Line Business Practice Location Address:
SUITE 100 C
Provider Business Practice Location Address City Name:
SIERRA VISTA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85635-2485
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-452-0144
Provider Business Practice Location Address Fax Number:
520-452-0075
Provider Enumeration Date:
07/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JENKINS
Authorized Official First Name:
JODY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
520-452-0144

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  23558 , 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: AZ0776250 . This is a "BCBS PROVIDER ID" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 322222 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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