Provider Demographics
NPI:1568749430
Name:SWDC WALK-IN CLINIC
Entity Type:Organization
Organization Name:SWDC WALK-IN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SERGIO
Authorized Official - Middle Name:
Authorized Official - Last Name:PENAHERRERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-344-6450
Mailing Address - Street 1:PO BOX 590
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85366-2325
Mailing Address - Country:US
Mailing Address - Phone:928-344-6450
Mailing Address - Fax:
Practice Address - Street 1:1881 W 24TH ST
Practice Address - Street 2:STE A
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-6297
Practice Address - Country:US
Practice Address - Phone:928-344-6450
Practice Address - Fax:928-344-6480
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHWEST DIABETES CENTER PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-07
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty