Healthcare Provider Details

I. General information

NPI: 1629252945
Provider Name (Legal Business Name): REPLOGLE MEDICAL CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2007
Last Update Date: 12/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11871 S FORTUNA RD
YUMA AZ
85367-7686
US

IV. Provider business mailing address

11871 S FORTUNA RD
YUMA AZ
85367-7686
US

V. Phone/Fax

Practice location:
  • Phone: 928-342-9020
  • Fax: 928-342-2158
Mailing address:
  • Phone: 928-342-9020
  • Fax: 928-342-2158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number2757
License Number StateAZ

VIII. Authorized Official

Name: DR. STEPHEN P REPLOGLE
Title or Position: PHYSICIAN
Credential: D.O.
Phone: 928-342-9020