1346591757 NPI number — MS. CONCHITA DOLORES SUTHERLAND LMT

Table of content: MS. CONCHITA DOLORES SUTHERLAND LMT (NPI 1346591757)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346591757 NPI number — MS. CONCHITA DOLORES SUTHERLAND LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUTHERLAND
Provider First Name:
CONCHITA
Provider Middle Name:
DOLORES
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SUTHERLAND
Provider Other First Name:
CHI
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMT
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1346591757
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 52
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ASH FORK
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86320-0052
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-924-0252
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
607 W GURLEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRESCOTT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86305-3619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-227-1899
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/25/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  MT-07772 , 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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