Provider Demographics
NPI:1225337207
Name:GOLD CANYON FAMILY PRACTICE
Entity Type:Organization
Organization Name:GOLD CANYON FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAITON
Authorized Official - Middle Name:
Authorized Official - Last Name:RUTKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-982-3691
Mailing Address - Street 1:6820 S KINGS RANCH RD STE 130
Mailing Address - Street 2:
Mailing Address - City:GOLD CANYON
Mailing Address - State:AZ
Mailing Address - Zip Code:85118-2959
Mailing Address - Country:US
Mailing Address - Phone:480-347-1321
Mailing Address - Fax:480-982-3692
Practice Address - Street 1:6820 S KINGS RANCH RD STE 130
Practice Address - Street 2:
Practice Address - City:GOLD CANYON
Practice Address - State:AZ
Practice Address - Zip Code:85118-2959
Practice Address - Country:US
Practice Address - Phone:480-347-1321
Practice Address - Fax:480-982-3692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-16
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care