Healthcare Provider Details

I. General information

NPI: 1144535626
Provider Name (Legal Business Name): PONDEROSA FAMILY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2010
Last Update Date: 12/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 S PONDEROSA ST
PAYSON AZ
85541-5541
US

IV. Provider business mailing address

PO BOX 2901
PAYSON AZ
85547-2901
US

V. Phone/Fax

Practice location:
  • Phone: 928-468-8603
  • Fax:
Mailing address:
  • Phone: 928-468-9280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number29337
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number29337
License Number StateAZ

VIII. Authorized Official

Name: DR. ALAN P MICHELS
Title or Position: PHYSICIAN
Credential:
Phone: 928-468-8603