Provider Demographics
NPI:1932349867
Name:SEDONA INTEGRATIVE MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:SEDONA INTEGRATIVE MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOL
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-284-0166
Mailing Address - Street 1:450 S WILLARD ST STE 101
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-6744
Mailing Address - Country:US
Mailing Address - Phone:928-284-0166
Mailing Address - Fax:928-284-1810
Practice Address - Street 1:450 S WILLARD ST STE 101
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-6744
Practice Address - Country:US
Practice Address - Phone:928-284-0166
Practice Address - Fax:928-284-1810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-05
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
AZ5669225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
69433Medicare UPIN