Provider Demographics
NPI:1255314225
Name:COPPER SUN ENTERPRISES, INC
Entity Type:Organization
Organization Name:COPPER SUN ENTERPRISES, INC
Other - Org Name:COPPER SUN MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:LAZARIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-425-8540
Mailing Address - Street 1:PO BOX 1783
Mailing Address - Street 2:
Mailing Address - City:CLAYPOOL
Mailing Address - State:AZ
Mailing Address - Zip Code:85532-1783
Mailing Address - Country:US
Mailing Address - Phone:928-425-8540
Mailing Address - Fax:866-679-2291
Practice Address - Street 1:157 W CEDAR ST
Practice Address - Street 2:
Practice Address - City:GLOBE
Practice Address - State:AZ
Practice Address - Zip Code:85501-2509
Practice Address - Country:US
Practice Address - Phone:928-425-8540
Practice Address - Fax:866-679-2291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-23
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11022216332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ11022216OtherAZ DEPT OF REVENUE TPT
AZAZ0274230OtherBCBS
AZ=========OtherTIN
AZ0764780001Medicare NSC