Healthcare Provider Details

I. General information

NPI: 1265841563
Provider Name (Legal Business Name): SONOITA SAGE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

3123 HWY 83 SUITE B
SONOITA AZ
85637-0843
US

IV. Provider business mailing address

PO BOX 843 SUITE B AZ HWY 83
SONOITA AZ
85637-0843
US

V. Phone/Fax

Practice location:
  • Phone: 520-415-0330
  • Fax: 760-705-8888
Mailing address:
  • Phone: 520-415-0330
  • Fax: 760-705-8888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberANP0071
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberANP0071
License Number StateAZ

VIII. Authorized Official

Name: MRS. ELAINE MARIAN HOOPER
Title or Position: NP/MEDICAL DIRECTOR
Credential: ANP/GNP
Phone: 520-603-5151