=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306969761
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPECTRUM HEALTH CARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2007
-----------------------------------------------------
Last Update Date | 05/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2143 E 5TH ST
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85281-3034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-464-8971
-----------------------------------------------------
Fax | 480-464-0364
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2143 E 5TH ST
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85281-3034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-464-8971
-----------------------------------------------------
Fax | 480-464-0364
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARTIN S LOCKE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-464-8971
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 03D0909740
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------