Healthcare Provider Details

I. General information

NPI: 1982890851
Provider Name (Legal Business Name): NEW RIVER FAMILY MEDICINE L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2007
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46641 N BLACK CANYON HWY STE 5
NEW RIVER AZ
85087-6941
US

IV. Provider business mailing address

46641 N BLACK CANYON HWY STE 5
NEW RIVER AZ
85087-6941
US

V. Phone/Fax

Practice location:
  • Phone: 623-465-8810
  • Fax: 623-465-1561
Mailing address:
  • Phone: 623-465-8810
  • Fax: 623-465-1561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3297
License Number StateAZ

VIII. Authorized Official

Name: DR. RANDY CHARLES HANCOCK
Title or Position: PRESIDENT
Credential: DO
Phone: 623-465-8810