Provider Demographics
NPI:1679280671
Name:ALTA MEDICAL CLINIC INC OF ARIZONA
Entity Type:Organization
Organization Name:ALTA MEDICAL CLINIC INC OF ARIZONA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETERSON
Authorized Official - Middle Name:
Authorized Official - Last Name:GO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-236-0338
Mailing Address - Street 1:4742 N 24TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-9107
Mailing Address - Country:US
Mailing Address - Phone:909-236-0338
Mailing Address - Fax:
Practice Address - Street 1:4742 N 24TH ST STE 300
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-9107
Practice Address - Country:US
Practice Address - Phone:909-236-0338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & NeuropsychiatryGroup - Multi-Specialty