Healthcare Provider Details

I. General information

NPI: 1770917007
Provider Name (Legal Business Name): SPECTRUM HEALTHCARE GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2013
Last Update Date: 06/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 S MAIN ST
COTTONWOOD AZ
86326-3907
US

IV. Provider business mailing address

8 E COTTONWOOD ST
COTTONWOOD AZ
86326-6237
US

V. Phone/Fax

Practice location:
  • Phone: 928-634-7534
  • Fax: 928-634-9642
Mailing address:
  • Phone: 928-203-5404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberOTC5537
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberOTC5537
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOTC5537
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOTC5537
License Number StateAZ

VIII. Authorized Official

Name: CONNIE SVALENG
Title or Position: CFO
Credential:
Phone: 928-634-2236