Healthcare Provider Details

I. General information

NPI: 1770556284
Provider Name (Legal Business Name): 51 MDOS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 MDOS PSC 3 BOX 2652
APO AP
96266
KR

IV. Provider business mailing address

2353 N 123RD DR
AVONDALE AZ
85323-6500
US

V. Phone/Fax

Practice location:
  • Phone: 315-874-7473
  • Fax:
Mailing address:
  • Phone: 623-535-8432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateAZ

VIII. Authorized Official

Name: JAMES LAMUNYON
Title or Position: PHYSICIAN ASSISTANT
Credential: PA-CERTIFIED
Phone: 315-784-7473