1760669600 NPI number — EMD MEDICAL SERVICES LLC

Table of content: (NPI 1760669600)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760669600 NPI number — EMD MEDICAL SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMD MEDICAL SERVICES 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:
CHERRY FAMILY PRACTICE
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:
1760669600
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
36470 N. 12TH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85086
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-634-1304
Provider Business Mailing Address Fax Number:
928-634-2887

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18850 E. SCHOOLHOUSE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLACK CANYON CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-374-5215
Provider Business Practice Location Address Fax Number:
623-374-8969
Provider Enumeration Date:
01/22/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TARUFELLI
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER-FNP
Authorized Official Telephone Number:
602-639-1320

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  AP2353 , 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)