Basic Information
| Provider Information | |||||||||
| NPI: | 1093812083 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STATCLINIX PLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | STATCLINIX - SHOW LOW | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9382 E BAHIA DR | ||||||||
| Address2: | SUITE B103 | ||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852601579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806824118 | ||||||||
| FaxNumber: | 4803747301 | ||||||||
| Practice Location | |||||||||
| Address1: | 680 E DEUCE OF CLUBS | ||||||||
| Address2: | SUITE B | ||||||||
| City: | SHOW LOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859014827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285372777 | ||||||||
| FaxNumber: | 9285372787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 04/03/2008 | ||||||||
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| AuthorizedOfficialLastName: | MCGUIRE | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 4805167058 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MBA, RN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | OTC 3916 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 052086 | 05 | AZ | MEDICAID |