1104102482 NPI number — SEGO MEDICAL ASSOCIATES LLC

Table of content: (NPI 1104102482)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104102482 NPI number — SEGO MEDICAL ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SEGO MEDICAL ASSOCIATES 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:
1104102482
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3361 HILLDALE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE HAVASU CITY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86406-9062
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-566-9958
Provider Business Mailing Address Fax Number:
928-680-6522

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2082 MESQUITE AVE
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
LAKE HAVASU CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86403-6710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-680-4233
Provider Business Practice Location Address Fax Number:
928-680-6522
Provider Enumeration Date:
10/31/2011

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH-TRYON
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/MEMBER
Authorized Official Telephone Number:
928-566-9958

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: L-1712856-3 . This is a "LLC REGISTRATION" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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