1962580118 NPI number — TRI-CITY EXPRESS CARE, PLLC

Table of content: (NPI 1962580118)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962580118 NPI number — TRI-CITY EXPRESS CARE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI-CITY EXPRESS CARE, PLLC
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:
6
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:
1962580118
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
890 W ELLIOT RD
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85233-5102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-545-1413
Provider Business Mailing Address Fax Number:
480-545-1434

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
920 E WILLIAMS FIELD RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85295-4880
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-855-9400
Provider Business Practice Location Address Fax Number:
480-782-1598
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DUNN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
PATRICK
Authorized Official Title or Position:
MEDICAL DIRECTOR/OWNER
Authorized Official Telephone Number:
480-545-1413

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  OTC3513 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QU0200X , with the licence number: OTC3513 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 870445 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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