Provider Demographics
NPI:1831577139
Name:ARIZONA IOM LLC
Entity type:Organization
Organization Name:ARIZONA IOM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:L
Authorized Official - Last Name:FORDYCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-458-6306
Mailing Address - Street 1:2907 SHELTER ISLAND DR.
Mailing Address - Street 2:SUITE 105-612
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92106-2743
Mailing Address - Country:US
Mailing Address - Phone:602-734-1405
Mailing Address - Fax:
Practice Address - Street 1:2301 WEST SANOQUE COURT
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85298
Practice Address - Country:US
Practice Address - Phone:720-503-5711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-07
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnosticGroup - Single Specialty