1285780767 NPI number — CRYSTAL CANYON ENT & FACIAL PLASTIC SURGERY PC

Table of content: (NPI 1285780767)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285780767 NPI number — CRYSTAL CANYON ENT & FACIAL PLASTIC SURGERY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRYSTAL CANYON ENT & FACIAL PLASTIC SURGERY PC
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:
1285780767
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1340 N RIM DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLAGSTAFF
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86001-3111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-774-1873
Provider Business Mailing Address Fax Number:
928-774-5525

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1340 N RIM DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLAGSTAFF
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86001-3111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-774-1873
Provider Business Practice Location Address Fax Number:
928-774-5525
Provider Enumeration Date:
01/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
PAMELA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
928-774-1873

Provider Taxonomy Codes

  • Taxonomy code: 207K00000X , with the licence number:  MD3000 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207YX0905X , with the licence number: MD3000 , 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: 316762 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1000074 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ0228870 . This is a "BCBSAZ" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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