Basic Information
| Provider Information | |||||||||
| NPI: | 1134491210 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ULTIMATE INTEGRATED PATIENT CARE PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10214 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853180214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807185986 | ||||||||
| FaxNumber: | 4806646813 | ||||||||
| Practice Location | |||||||||
| Address1: | 13714 N PLAZA DEL RIO BLVD | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853814874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807185986 | ||||||||
| FaxNumber: | 4806646813 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2012 | ||||||||
| LastUpdateDate: | 02/03/2012 | ||||||||
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| AuthorizedOfficialLastName: | LOMAN | ||||||||
| AuthorizedOfficialFirstName: | VALARIE | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 4807185986 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311Z00000X | 005286 | AZ | Y | Nursing & Custodial Care Facilities | Custodial Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 456982 | 05 | AZ | MEDICAID |