1962697706 NPI number — MATTHEW DORCHESTER, DC, CCSP, LLC

Table of content: (NPI 1962697706)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962697706 NPI number — MATTHEW DORCHESTER, DC, CCSP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MATTHEW DORCHESTER, DC, CCSP, 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:
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:
1962697706
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8894 E RUSTY SPUR PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCOTTSDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85255-9166
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-991-3399
Provider Business Mailing Address Fax Number:
480-905-0815

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18325 N ALLIED WAY
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85054-3105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-991-3399
Provider Business Practice Location Address Fax Number:
480-905-0815
Provider Enumeration Date:
09/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DORCHESTER
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
480-991-3399

Provider Taxonomy Codes

  • Taxonomy code: 111NS0005X , with the licence number:  1578 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: 10597 , 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: Z117689 . This is a "PTAN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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