Healthcare Provider Details

I. General information

NPI: 1679730493
Provider Name (Legal Business Name): BILLY CREEK CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2008
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 W WHITE MOUNTAIN BLVD
LAKESIDE AZ
85929-7002
US

IV. Provider business mailing address

PO BOX 878
SPRINGERVILLE AZ
85938-0878
US

V. Phone/Fax

Practice location:
  • Phone: 928-367-4040
  • Fax: 928-367-4042
Mailing address:
  • Phone: 928-333-5333
  • Fax: 928-333-5100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number32794
License Number StateAZ

VIII. Authorized Official

Name: JENNIFER L LARUE
Title or Position: BILLING
Credential:
Phone: 928-333-5333