=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720421274
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAGUARO PRIMARY CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2013
-----------------------------------------------------
Last Update Date | 09/03/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 511 W 8TH ST SUITE 201
-----------------------------------------------------
City | ODESSA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79761-4406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-332-8219
-----------------------------------------------------
Fax | 432-332-8214
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 511 W 8TH ST SUITE 201
-----------------------------------------------------
City | ODESSA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79761-4406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-770-8545
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FAMILY NURSE PRACTITIONER
-----------------------------------------------------
Name | MR. MATTHEW A SANCHEZ
-----------------------------------------------------
Credential | FNP-C
-----------------------------------------------------
Telephone | 432-332-8219
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 728353
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------