Healthcare Provider Details

I. General information

NPI: 1962621375
Provider Name (Legal Business Name): EASTERN ARIZONA ORTHOPEDIC CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 06/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5860 S HOSPITAL DR STE103
GLOBE AZ
85501-9449
US

IV. Provider business mailing address

5860 S HOSPITAL DR STE 103
GLOBE AZ
85501-9449
US

V. Phone/Fax

Practice location:
  • Phone: 928-425-3193
  • Fax: 928-425-4771
Mailing address:
  • Phone: 928-425-3193
  • Fax: 928-425-4771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number11804
License Number StateAZ

VIII. Authorized Official

Name: MARY TERESA ACOSTA
Title or Position: OFFICE MANAGER
Credential:
Phone: 928-425-3193