=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841682002
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HIGH DESERT URGENT CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2015
-----------------------------------------------------
Last Update Date | 02/25/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 77 E FRY BLVD
-----------------------------------------------------
City | SIERRA VISTA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85635-1813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-459-8915
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4845 PASEO MANOLETE
-----------------------------------------------------
City | SIERRA VISTA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85635-4640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | BRETT JOHNSON
-----------------------------------------------------
Credential | D.O
-----------------------------------------------------
Telephone | 520-559-1861
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------