MEDICARE: PRESCOTT VAMC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QV0200X	VA Clinic/Center

General Provider Information

NPI Number	:	1437547734
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRESCOTT VAMC

Provider Business Mailing Address
First Line	:	PO BOX 94411
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44101-4411
Country	:	US
Telephone Number	:	702-341-3152
Fax Number	:

Provider Business Practice Location Address
First Line	:	167 NORTH MAIN STREET
Second Line	:
City	:	TUBA CITY
State	:	AZ
Zip	:	86045-9998
Country	:	US
Telephone Number	:	702-341-3152
Fax Number	:

Authorized Official
Title or Position	:	NPI TEAM MEMBER
Name	:	ERIN POTTER
Credential	:
Telephone Number	:	202-382-2579

Provider Enumeration Date	:	01/08/2015
Last Update Date	:	11/01/2017

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