Healthcare Provider Details

I. General information

NPI: 1538714092
Provider Name (Legal Business Name): PRESCOTT COMPLETE CARE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2019
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1947 COMMERCE CENTER CIRCLE SUITE A
PRESCOTT AZ
86301
US

IV. Provider business mailing address

1947 COMMERCE CENTER CIRCLE SUITE A
PRESCOTT AZ
86301
US

V. Phone/Fax

Practice location:
  • Phone: 928-458-5723
  • Fax: 928-237-1787
Mailing address:
  • Phone: 928-458-5723
  • Fax: 928-237-1787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH VICCICA
Title or Position: MEMBER
Credential:
Phone: 570-299-0037