1750604989 NPI number — SUNRIDGE MEDICAL WELLNES CENTER

Table of content: (NPI 1750604989)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750604989 NPI number — SUNRIDGE MEDICAL WELLNES CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNRIDGE MEDICAL WELLNES CENTER
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:
1750604989
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14200 N NORTHSIGHT BLVD
Provider Second Line Business Mailing Address:
SUITE 160
Provider Business Mailing Address City Name:
SCOTTSDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85260-3947
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-659-9135
Provider Business Mailing Address Fax Number:
800-659-9035

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14200 N NORTHSIGHT BLVD
Provider Second Line Business Practice Location Address:
SUITE 160
Provider Business Practice Location Address City Name:
SCOTTSDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85260-3947
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-659-9135
Provider Business Practice Location Address Fax Number:
800-659-9035
Provider Enumeration Date:
03/02/2010

Additional Information

Authorized Official

Authorized Official Last Name:
FRANCO
Authorized Official First Name:
GIOACCHINO
Authorized Official Middle Name:
VINCENZO
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
480-659-9155

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  04-839 , 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: 04839 . This is a "STATE LICENSURE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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