Healthcare Provider Details

I. General information

NPI: 1700362738
Provider Name (Legal Business Name): FOUR CORNERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 07/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1704 LLANO ST STE B
SANTA FE NM
87505-5415
US

IV. Provider business mailing address

5761 W PARK AVE
CHANDLER AZ
85226-1241
US

V. Phone/Fax

Practice location:
  • Phone: 520-339-9276
  • Fax:
Mailing address:
  • Phone: 520-339-9726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNM

VIII. Authorized Official

Name: MR. OSAMA WALI
Title or Position: GENERAL MANAGER
Credential:
Phone: 520-339-9726