Healthcare Provider Details

I. General information

NPI: 1073986923
Provider Name (Legal Business Name): PAINTED DESERT PRIMARY CARE & GYNECOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2015
Last Update Date: 11/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 SILVER CREEK RD BLDG. B, STE. 101A
BULLHEAD CITY AZ
86442-8476
US

IV. Provider business mailing address

2020 SILVER CREEK RD BLDG. B, STE. 101A
BULLHEAD CITY AZ
86442-8476
US

V. Phone/Fax

Practice location:
  • Phone: 928-704-4336
  • Fax: 928-704-0410
Mailing address:
  • Phone: 928-704-4336
  • Fax: 928-704-0410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number3681
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number3681
License Number StateAZ

VIII. Authorized Official

Name: TERESA M BORCHERS
Title or Position: DIRECTOR
Credential: D.O.
Phone: 928-704-4336