Provider Demographics
NPI: | 1134472574 |
---|---|
Name: | NCMC SPECIALTY CLINIC |
Entity Type: | Organization |
Organization Name: | NCMC SPECIALTY CLINIC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CFO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | DENNIS |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | LARAWAY |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 602-747-4000 |
Mailing Address - Street 1: | 2901 N CENTRAL AVE STE 160 |
Mailing Address - Street 2: | |
Mailing Address - City: | PHOENIX |
Mailing Address - State: | AZ |
Mailing Address - Zip Code: | 85012-2702 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 608 E HARMONY RD STE 101 |
Practice Address - Street 2: | |
Practice Address - City: | FORT COLLINS |
Practice Address - State: | CO |
Practice Address - Zip Code: | 80525-3210 |
Practice Address - Country: | US |
Practice Address - Phone: | 970-203-2400 |
Practice Address - Fax: | 970-203-2410 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | BANNER HEALTH |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2012-10-23 |
Last Update Date: | 2021-12-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QM1300X | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
C450638 | Medicare PIN |