Provider Demographics
NPI:1942217088
Name:COPPER QUEEN MEDICAL ASSOCIATES DOUGLAS
Entity Type:Organization
Organization Name:COPPER QUEEN MEDICAL ASSOCIATES DOUGLAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:CARRIZOZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-364-7659
Mailing Address - Street 1:100 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:AZ
Mailing Address - Zip Code:85607-2859
Mailing Address - Country:US
Mailing Address - Phone:520-364-7659
Mailing Address - Fax:520-364-8541
Practice Address - Street 1:100 E 5TH ST
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:AZ
Practice Address - Zip Code:85607-2859
Practice Address - Country:US
Practice Address - Phone:520-364-7659
Practice Address - Fax:520-364-8541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC-3364261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center