Provider Demographics
NPI:1023041654
Name:LEVEL 4 MEDICAL PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:LEVEL 4 MEDICAL PROFESSIONAL CORPORATION
Other - Org Name:FOOTHILLS WALK-IN MEDICAL AND URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:SMOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-345-2150
Mailing Address - Street 1:11274 S FORTUNA RD
Mailing Address - Street 2:STE I 4
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85367-7847
Mailing Address - Country:US
Mailing Address - Phone:928-345-2150
Mailing Address - Fax:928-345-2151
Practice Address - Street 1:11274 S FORTUNA RD
Practice Address - Street 2:STE I 4
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85367-7847
Practice Address - Country:US
Practice Address - Phone:928-345-2150
Practice Address - Fax:928-345-2151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC2699146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, BasicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ28500Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER