Provider Demographics
NPI:1790848133
Name:VERDE VALLEY SEDONA ADVANCED IMAGING DIAGNOSTICS LLC
Entity Type:Organization
Organization Name:VERDE VALLEY SEDONA ADVANCED IMAGING DIAGNOSTICS LLC
Other - Org Name:ADVANCED IMAGING DIAGNOSTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:MOYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-778-1251
Mailing Address - Street 1:47 N FRENCH DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86303-6247
Mailing Address - Country:US
Mailing Address - Phone:928-778-1251
Mailing Address - Fax:928-778-7834
Practice Address - Street 1:115 S CANDY LN
Practice Address - Street 2:BLDG. A
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4105
Practice Address - Country:US
Practice Address - Phone:928-649-9999
Practice Address - Fax:928-649-0058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC2772261QR0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ937071Medicaid
AZZ64560Medicare ID - Type Unspecified