1336561521 NPI number — COPPER HEALTH ORO VALLEY LLC

Table of content: (NPI 1336561521)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336561521 NPI number — COPPER HEALTH ORO VALLEY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COPPER HEALTH ORO VALLEY 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:
6
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:
1336561521
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3602 E GREENWAY RD
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85032-4648
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-368-8203
Provider Business Mailing Address Fax Number:
602-368-8211

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1119 E RANCHO VISTOSO BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORO VALLEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85755-9106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-823-4669
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/08/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MCNELLIS
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
TERRENCE
Authorized Official Title or Position:
OWNER/MANAGER
Authorized Official Telephone Number:
612-991-9062

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NCI2725 , 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: NCI2725 . This is a "ARIZONA DEPT. OF HEALTH SERVICES" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".