Healthcare Provider Details

I. General information

NPI: 1972902997
Provider Name (Legal Business Name): MOUNTAIN FAMILY CARE AND WALK IN PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 08/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 E DEUCE OF CLUBS
SHOW LOW AZ
85901-4808
US

IV. Provider business mailing address

PO BOX 2680
SHOW LOW AZ
85902-2680
US

V. Phone/Fax

Practice location:
  • Phone: 928-532-3926
  • Fax: 928-367-4916
Mailing address:
  • Phone: 928-532-3926
  • Fax: 928-367-4916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number45758
License Number StateAZ

VIII. Authorized Official

Name: DR. BRYAN SEAN SMITHSON
Title or Position: OWNER
Credential: M.D.
Phone: 928-532-3926