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
State | License ID | Taxonomies |
---|---|---|
AZ | OTC-3364 | 261Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261Q00000X | Ambulatory Health Care Facilities | Clinic/Center |