Basic Information
| Provider Information | |||||||||
| NPI: | 1568875771 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LA PAZ REGIONAL HOSPITAL INC., DBA PARKER PODIATRY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 W MOHAVE RD | ||||||||
| Address2: | |||||||||
| City: | PARKER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853446349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286699201 | ||||||||
| FaxNumber: | 9286697409 | ||||||||
| Practice Location | |||||||||
| Address1: | 1713 S KOFA AVE STE K | ||||||||
| Address2: | |||||||||
| City: | PARKER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853446402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286693033 | ||||||||
| FaxNumber: | 9286694416 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2014 | ||||||||
| LastUpdateDate: | 02/27/2019 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9286697300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | H0138 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 031317 | 01 | AZ | MEDICARE OSCAR | OTHER | 480046 | 05 | AZ | MEDICAID |