Provider Demographics
NPI:1669883864
Name:ALTEA MEDICAL CLINIC PLLC
Entity type:Organization
Organization Name:ALTEA MEDICAL CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VERNON
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAVEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-726-2500
Mailing Address - Street 1:1210 W 24TH ST STE 2
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-6227
Mailing Address - Country:US
Mailing Address - Phone:928-726-2500
Mailing Address - Fax:928-726-7853
Practice Address - Street 1:1210 W 24TH ST STE 2
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-6227
Practice Address - Country:US
Practice Address - Phone:928-726-2500
Practice Address - Fax:928-726-7853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-12
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZPENDINGMedicaid