=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013270354
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE BONE AND JOINT CENTER OF YUMA, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2012
-----------------------------------------------------
Last Update Date | 06/21/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1763 W 24TH ST SUITE 102
-----------------------------------------------------
City | YUMA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85364-6219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-726-1556
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4685
-----------------------------------------------------
City | YUMA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85366-2437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MEMBER
-----------------------------------------------------
Name | RON CLARK
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 928-726-1556
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 45972
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------