Healthcare Provider Details

I. General information

NPI: 1568749430
Provider Name (Legal Business Name): SWDC WALK-IN CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2011
Last Update Date: 03/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1881 W 24TH ST STE A
YUMA AZ
85364-6297
US

IV. Provider business mailing address

PO BOX 590
YUMA AZ
85366-2325
US

V. Phone/Fax

Practice location:
  • Phone: 928-344-6450
  • Fax: 928-344-6480
Mailing address:
  • Phone: 928-344-6450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateAZ

VIII. Authorized Official

Name: SERGIO PENAHERRERA
Title or Position: OWNER
Credential: MD
Phone: 928-344-6450