MEDICARE: DESERT MOUNTAIN ORTHOPAEDICS & SPORTS MEDICINE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician

General Provider Information

NPI Number	:	1356695431
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESERT MOUNTAIN ORTHOPAEDICS & SPORTS MEDICINE LLC

Provider Business Mailing Address
First Line	:	PO BOX 27340
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85061-7340
Country	:	US
Telephone Number	:	602-943-9200
Fax Number	:	602-216-3000

Provider Business Practice Location Address
First Line	:	297 LAKE HAVASU AVE S
Second Line	:	SUITE 108
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-6526
Country	:	US
Telephone Number	:	928-854-3333
Fax Number	:	928-854-3335

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DAVID C. KING
Credential	:	M.D.
Telephone Number	:	928-854-3333

Provider Enumeration Date	:	10/29/2012
Last Update Date	:	10/29/2012

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