1962841742 NPI number — THE ORTHO JOINT OF ARIZONA, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962841742 NPI number — THE ORTHO JOINT OF ARIZONA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE ORTHO JOINT 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:
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:
1962841742
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1149
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85380
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-583-2073
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12361 W BOLA DR
Provider Second Line Business Practice Location Address:
#100
Provider Business Practice Location Address City Name:
SURPRISE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85378-9021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-584-5626
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/14/2013

Additional Information

Authorized Official

Authorized Official Last Name:
TSAO
Authorized Official First Name:
AUDREY
Authorized Official Middle Name:
Authorized Official Title or Position:
PROVIDER
Authorized Official Telephone Number:
623-583-2073

Provider Taxonomy Codes

  • Taxonomy code: 207XS0114X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PENDING , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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