Provider Demographics
NPI:1265692792
Name:CLINICA DR ALFONSO SALAS PC
Entity type:Organization
Organization Name:CLINICA DR ALFONSO SALAS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANNET
Authorized Official - Middle Name:
Authorized Official - Last Name:DECARDENAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-897-1175
Mailing Address - Street 1:PO BOX 355
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85311-0355
Mailing Address - Country:US
Mailing Address - Phone:623-931-2444
Mailing Address - Fax:623-931-1099
Practice Address - Street 1:7734 N 59TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-7816
Practice Address - Country:US
Practice Address - Phone:623-931-2444
Practice Address - Fax:623-931-1099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29615208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ000083Medicaid
AZ560337Medicaid
AZ587766Medicaid
AZ173414Medicaid
AZ616245Medicaid
AZ560337Medicaid
AZ143661Medicare PIN
AZ173414Medicaid