Healthcare Provider Details

I. General information

NPI: 1669991485
Provider Name (Legal Business Name): ASURA HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2017
Last Update Date: 09/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12075 E STATE ROUTE 69 STE B
DEWEY AZ
86327-4517
US

IV. Provider business mailing address

303 E GURLEY ST UNIT 479
PRESCOTT AZ
86301-3804
US

V. Phone/Fax

Practice location:
  • Phone: 405-590-8861
  • Fax: 888-389-7077
Mailing address:
  • Phone: 405-590-8861
  • Fax: 888-389-7077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberAP3224
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number41469
License Number StateAZ

VIII. Authorized Official

Name: DR. JOHN S GILLIAM
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 405-590-8861