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General NPI Number Information
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NPI Number | 1396956918
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Entity Type | Organization
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Legal Business Name | MOON VALLEY MEDICAL CENTER PC
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Dates
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Enumeration Date | 05/25/2007
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Last Update Date | 11/23/2009
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Provider Practice Location Address
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Address Line | 13206 NORTH 7TH STREET
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City | PHOENIX
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State | AZ
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Zip | 85022
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Country | US
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Telephone | 602-866-2277
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Fax | 602-866-7998
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Provider Business Mailing Address
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Address Line | 13206 NORTH 7TH STREET
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City | PHOENIX
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State | AZ
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Zip | 85022
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Country | US
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Telephone | 602-866-2277
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Fax | 602-866-7998
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LESLIE DIANE EDISON
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Credential | DO
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Telephone | 602-866-2277
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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 | 2491
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License Number State | AZ
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