1760623870 NPI number — VILLAGE OF OAK CREEK MEDICAL CLINIC LLC

Table of content: (NPI 1760623870)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760623870 NPI number — VILLAGE OF OAK CREEK MEDICAL CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VILLAGE OF OAK CREEK MEDICAL CLINIC 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:
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:
1760623870
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1936
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COTTONWOOD
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86326-1936
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-634-0665
Provider Business Mailing Address Fax Number:
928-634-0337

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6486 HWY 179
Provider Second Line Business Practice Location Address:
STE 107
Provider Business Practice Location Address City Name:
SEDONA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86351-7993
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-284-3236
Provider Business Practice Location Address Fax Number:
928-284-2531
Provider Enumeration Date:
03/19/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ZARETZKY
Authorized Official First Name:
BARRY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
928-284-3236

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  23452 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: 23452 , 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: 357287 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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