Provider Demographics
NPI:1265694616
Name:GOLD CANYON URGENT CARE
Entity type:Organization
Organization Name:GOLD CANYON URGENT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:DAITON
Authorized Official - Middle Name:F
Authorized Official - Last Name:RUTKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-982-3691
Mailing Address - Street 1:6832 S KINGS RANCH RD STE 2
Mailing Address - Street 2:PMB #51
Mailing Address - City:GOLD CANYON
Mailing Address - State:AZ
Mailing Address - Zip Code:85218-2929
Mailing Address - Country:US
Mailing Address - Phone:480-213-3289
Mailing Address - Fax:
Practice Address - Street 1:6820 S KINGS RANCH RD
Practice Address - Street 2:
Practice Address - City:GOLD CANYON
Practice Address - State:AZ
Practice Address - Zip Code:85218-2926
Practice Address - Country:US
Practice Address - Phone:480-213-3289
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
6219480001Medicare NSC