Healthcare Provider Details

I. General information

NPI: 1679280671
Provider Name (Legal Business Name): ALTA MEDICAL CLINIC INC OF ARIZONA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2022
Last Update Date: 10/31/2022
Certification Date: 10/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4742 N 24TH ST STE 300
PHOENIX AZ
85016-9107
US

IV. Provider business mailing address

4742 N 24TH ST STE 300
PHOENIX AZ
85016-9107
US

V. Phone/Fax

Practice location:
  • Phone: 909-236-0338
  • Fax:
Mailing address:
  • Phone: 909-236-0338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: PETERSON GO
Title or Position: PRESIDENT
Credential:
Phone: 909-236-0338