Provider Demographics
NPI:1568875771
Name:LA PAZ REGIONAL HOSPITAL INC., DBA PARKER PODIATRY
Entity Type:Organization
Organization Name:LA PAZ REGIONAL HOSPITAL INC., DBA PARKER PODIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-669-7300
Mailing Address - Street 1:1200 W MOHAVE RD
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:AZ
Mailing Address - Zip Code:85344-6349
Mailing Address - Country:US
Mailing Address - Phone:928-669-9201
Mailing Address - Fax:928-669-7409
Practice Address - Street 1:1713 S KOFA AVE STE K
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-6402
Practice Address - Country:US
Practice Address - Phone:928-669-3033
Practice Address - Fax:928-669-4416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-05
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH0138213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ031317OtherMEDICARE OSCAR
AZ480046Medicaid