Basic Information
| Provider Information | |||||||||
| NPI: | 1558387845 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TWIN PEAKS MEDICAL ASSOCIATES PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FASTRAX URGENT CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2002 N STOCKTON HILL RD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864014698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287533303 | ||||||||
| FaxNumber: | 9287533603 | ||||||||
| Practice Location | |||||||||
| Address1: | 2002 N STOCKTON HILL RD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864014698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287533303 | ||||||||
| FaxNumber: | 9287533603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 04/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | SCHMIDT | ||||||||
| AuthorizedOfficialFirstName: | DONOVAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PHYSICIAN PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9287533303 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | OTC3597 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 850166 | 05 | AZ | MEDICAID |