Provider Demographics
NPI:1730651969
Name:LEFT OF BANG LCC
Entity Type:Organization
Organization Name:LEFT OF BANG LCC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BROCK
Authorized Official - Middle Name:M
Authorized Official - Last Name:BEVELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-826-3833
Mailing Address - Street 1:1201 E COOLEY ST STE D
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-5145
Mailing Address - Country:US
Mailing Address - Phone:928-826-3833
Mailing Address - Fax:
Practice Address - Street 1:1201 E COOLEY ST STE D
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-5145
Practice Address - Country:US
Practice Address - Phone:928-826-3833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-28
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)