Provider Demographics
NPI:1255846788
Name:LDR MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:LDR MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER, BUSINESS OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:ROMERO
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:928-289-6093
Mailing Address - Street 1:305 W SECOND ST
Mailing Address - Street 2:
Mailing Address - City:WINSLOW
Mailing Address - State:AZ
Mailing Address - Zip Code:86047-3406
Mailing Address - Country:US
Mailing Address - Phone:928-289-6093
Mailing Address - Fax:928-289-6787
Practice Address - Street 1:305 W SECOND ST
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047-3406
Practice Address - Country:US
Practice Address - Phone:928-289-6093
Practice Address - Fax:928-289-6787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-06
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3306261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1255575411Medicaid