Healthcare Provider Details

I. General information

NPI: 1487605481
Provider Name (Legal Business Name): VAL VISTA LAKES FAMILY MEDICINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2006
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3331 E BASELINE RD
GILBERT AZ
85234-2633
US

IV. Provider business mailing address

3331 E BASELINE RD
GILBERT AZ
85234-2633
US

V. Phone/Fax

Practice location:
  • Phone: 480-545-1100
  • Fax: 480-545-7181
Mailing address:
  • Phone: 480-545-1100
  • Fax: 480-545-7181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. KENT HATFIELD
Title or Position: PRESIDENT/CEO
Credential: DO
Phone: 480-545-1100