Healthcare Provider Details

I. General information

NPI: 1932255791
Provider Name (Legal Business Name): COPPER STATE ORTHOPEDICS, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 04/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 E MCDOWELL RD SUITE A
PHOENIX AZ
85006-2625
US

IV. Provider business mailing address

1002 E MCDOWELL RD SUITE A
PHOENIX AZ
85006-2625
US

V. Phone/Fax

Practice location:
  • Phone: 602-262-2663
  • Fax: 602-258-3008
Mailing address:
  • Phone: 602-262-2663
  • Fax: 602-258-3008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number22049
License Number StateAZ

VIII. Authorized Official

Name: CHAR L MANLEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 602-262-2663