Basic Information
| Provider Information | |||||||||
| NPI: | 1457594210 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BANNER MOUNTAIN VISTA ORTHOPAEDIC MEDICAL CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1441 N 12TH ST | ||||||||
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| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850062837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027474000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5890 W 13TH ST | ||||||||
| Address2: | STE 101 | ||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806344821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703480020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2009 | ||||||||
| LastUpdateDate: | 04/09/2009 | ||||||||
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| AuthorizedOfficialLastName: | DAHLEN | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6027474000 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BANNER HEALTH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
No ID Information.