Basic Information
| Provider Information | |||||||||
| NPI: | 1295982353 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NCMC SPECIALTY CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2901 N CENTRAL AVE STE 160 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027474000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1800 15TH ST | ||||||||
| Address2: | SUITE 340 | ||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806314500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703784593 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2008 | ||||||||
| LastUpdateDate: | 12/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | LARAWAY | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6027474000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BANNER HEALTH | ||||||||
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| NPICertificationDate: | 12/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 59877031 | 05 | CO | MEDICAID |