Provider Demographics
NPI:1689272700
Name:PEDIATRIC MULTICARE WEST, LLC
Entity Type:Organization
Organization Name:PEDIATRIC MULTICARE WEST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:RAFFLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-242-1503
Mailing Address - Street 1:316 W. WHITE MOUNTAIN BLVD.
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929
Mailing Address - Country:US
Mailing Address - Phone:928-358-4620
Mailing Address - Fax:928-358-5319
Practice Address - Street 1:316 W. WHITE MOUNTAIN BLVD.
Practice Address - Street 2:SUITE A
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929
Practice Address - Country:US
Practice Address - Phone:928-358-4620
Practice Address - Fax:928-358-5319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ619449Medicaid