MEDICARE: PINAL COUNTY ARIZONA

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	251K00000X	Public Health or Welfare Agency	OTC3524	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720411424
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINAL COUNTY ARIZONA

Provider Business Mailing Address
First Line	:	PO BOX 2945
Second Line	:
City	:	FLORENCE
State	:	AZ
Zip	:	85132-3055
Country	:	US
Telephone Number	:	520-866-7319
Fax Number	:	520-866-7066

Provider Business Practice Location Address
First Line	:	110 S MAIN ST
Second Line	:
City	:	MAMMOTH
State	:	AZ
Zip	:	85618
Country	:	US
Telephone Number	:	520-866-7319
Fax Number	:	520-866-7066

Authorized Official
Title or Position	:	ACCOUNT CLERK-BILLING
Name	:	SUSIE C ESCALANTE
Credential	:
Telephone Number	:	520-866-7319

Provider Enumeration Date	:	08/16/2013
Last Update Date	:	08/16/2013

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Directions to “PINAL COUNTY ARIZONA ” Practice Location

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