Provider Demographics
NPI:1720480312
Name:SONOITA SAGE CLINIC, PLLC
Entity Type:Organization
Organization Name:SONOITA SAGE CLINIC, PLLC
Other - Org Name:SONOITA SAGE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:MARIAN
Authorized Official - Last Name:HOOPER
Authorized Official - Suffix:
Authorized Official - Credentials:ANP/GNP, BC
Authorized Official - Phone:520-415-0330
Mailing Address - Street 1:PO BOX 843
Mailing Address - Street 2:
Mailing Address - City:SONOITA
Mailing Address - State:AZ
Mailing Address - Zip Code:85637-0843
Mailing Address - Country:US
Mailing Address - Phone:520-415-0330
Mailing Address - Fax:
Practice Address - Street 1:3123 ARIZONA HWY 83 B
Practice Address - Street 2:
Practice Address - City:SONOITA
Practice Address - State:AZ
Practice Address - Zip Code:85637
Practice Address - Country:US
Practice Address - Phone:520-415-0330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-25
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP6266261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZQ61213Medicare UPIN