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General NPI Number Information
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NPI Number | 1184754640
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Entity Type | Organization
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Legal Business Name | SCOTT S EKDAHL
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Dates
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Enumeration Date | 03/06/2007
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Last Update Date | 07/19/2012
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Provider Practice Location Address
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Address Line | 474 N HWY 89
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City | CHINO VALLEY
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State | AZ
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Zip | 86323-5993
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Country | US
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Telephone | 928-636-4355
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Fax | 928-636-0754
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Provider Business Mailing Address
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Address Line | 474 N HWY 89
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City | CHINO VALLEY
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State | AZ
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Zip | 86323-5993
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Country | US
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Telephone | 928-636-4355
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Fax | 928-636-0754
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DR. SCOTT S EKDAHL
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Credential | DO
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Telephone | 928-636-4355
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | OTC2733
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License Number State | AZ
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