1972806834 NPI number — DESERT RIDGE URGENT CARE CENTERS

Table of content: (NPI 1972806834)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972806834 NPI number — DESERT RIDGE URGENT CARE CENTERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESERT RIDGE URGENT CARE CENTERS
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:
KYRENE URGENT CARE
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:
1972806834
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16515 S 40TH ST
Provider Second Line Business Mailing Address:
SUITE 139
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85048-0558
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-706-0174
Provider Business Mailing Address Fax Number:
480-706-0117

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 S KYRENE RD
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
CHANDLER
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85226-4675
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-706-0174
Provider Business Practice Location Address Fax Number:
480-706-0117
Provider Enumeration Date:
12/15/2010

Additional Information

Authorized Official

Authorized Official Last Name:
PETTIT
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER / PHYSICIAN
Authorized Official Telephone Number:
480-706-0174

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  3344 , 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)





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