1568697282 NPI number — ABUNDANT HEALTH FAMILY PRACTICE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568697282 NPI number — ABUNDANT HEALTH FAMILY PRACTICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ABUNDANT HEALTH FAMILY PRACTICE
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:
1568697282
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2055 W HOSPITAL DR
Provider Second Line Business Mailing Address:
SUITE 295
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85704-7892
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-326-1457
Provider Business Mailing Address Fax Number:
520-326-1464

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2055 W HOSPITAL DR
Provider Second Line Business Practice Location Address:
SUITE 295
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85704-7892
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-326-1457
Provider Business Practice Location Address Fax Number:
520-326-1464
Provider Enumeration Date:
05/26/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GORDON
Authorized Official First Name:
RACHEL
Authorized Official Middle Name:
E
Authorized Official Title or Position:
CO OWNER
Authorized Official Telephone Number:
520-326-1457

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 881707 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 526013 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 431655 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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