Basic Information
| Provider Information | |||||||||
| NPI: | 1104228337 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN LUIS WALK-IN CLINIC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 617 | ||||||||
| Address2: | |||||||||
| City: | SOMERTON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853500617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283157910 | ||||||||
| FaxNumber: | 9287226113 | ||||||||
| Practice Location | |||||||||
| Address1: | 1896 E BABBIT LN | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853367820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287226112 | ||||||||
| FaxNumber: | 9287226113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2014 | ||||||||
| LastUpdateDate: | 05/01/2020 | ||||||||
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| AuthorizedOfficialLastName: | AGUIRRE | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 9283157910 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAN LUIS WALK-IN CLINIC, INC. | ||||||||
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| AuthorizedOfficialCredential: | R.D. | ||||||||
| NPICertificationDate: | 05/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 943681 | 05 | AZ | MEDICAID | OTC3530 | 01 | AZ | ADHS LICENSE | OTHER |