=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578979118
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WHITE MOUNTAIN SURGICAL SPECIALIST
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2014
-----------------------------------------------------
Last Update Date | 07/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2650 E SHOW LOW LAKE RD STE 2
-----------------------------------------------------
City | SHOW LOW
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85901-7955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-537-4240
-----------------------------------------------------
Fax | 928-537-4541
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2650 E SHOW LOW LAKE RD STE 2
-----------------------------------------------------
City | SHOW LOW
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85901-7955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-537-4240
-----------------------------------------------------
Fax | 928-537-4541
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | ADRIANNE M PEREZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 928-537-4240
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302F00000X
-----------------------------------------------------
Taxonomy Name | Exclusive Provider Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------