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General NPI Number Information
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NPI Number | 1720110984
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Entity Type | Organization
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Legal Business Name | PRESCOTT GASTROENTEROLOGY
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Dates
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Enumeration Date | 03/12/2007
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Last Update Date | 08/27/2010
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Provider Practice Location Address
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Address Line | 811 AINSWORTH DR STE 103
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City | PRESCOTT
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State | AZ
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Zip | 86301-1687
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Country | US
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Telephone | 928-771-5548
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Fax | 928-771-5549
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Provider Business Mailing Address
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Address Line | 811 AINSWORTH DR STE 103
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City | PRESCOTT
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State | AZ
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Zip | 86301-1687
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Country | US
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Telephone | 928-771-5548
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Fax | 928-771-5549
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. DEBBIE MARIE DE LUNA
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Credential |
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Telephone | 928-771-5548
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 22747
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License Number State | AZ
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