1578945572 NPI number — ERIC CARMEN BETANCOURT PMHNP-BC

Table of content: ERIC CARMEN BETANCOURT PMHNP-BC (NPI 1578945572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578945572 NPI number — ERIC CARMEN BETANCOURT PMHNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BETANCOURT
Provider First Name:
ERIC
Provider Middle Name:
CARMEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PMHNP-BC
Provider Gender Code:
M

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:
1578945572
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3450 N 3RD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85012-2331
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-257-9339
Provider Business Mailing Address Fax Number:
602-265-8533

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1424 S 7TH AVE
Provider Second Line Business Practice Location Address:
BUILDING B
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85007-3902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-257-8970
Provider Business Practice Location Address Fax Number:
602-265-8533
Provider Enumeration Date:
06/25/2015

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: 363LP0808X , with the licence number:  AP7918 , 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)





Copyright © 2007-2024 www.npivalidator.com