Provider Demographics
NPI:1376742205
Name:WAARA FAMILY MEDICINE, LLC
Entity Type:Organization
Organization Name:WAARA FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SLOCUM WAARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-445-5339
Mailing Address - Street 1:1672 OAKLAWN DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-1106
Mailing Address - Country:US
Mailing Address - Phone:928-445-5339
Mailing Address - Fax:928-445-3664
Practice Address - Street 1:1672 OAKLAWN DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1106
Practice Address - Country:US
Practice Address - Phone:928-445-5339
Practice Address - Fax:928-445-3664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36449261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ116937Medicare PIN