Basic Information
| Provider Information | |||||||||
| NPI: | 1811328560 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AFC OF QUEEN CREEK, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2980 N BEVERLY GLEN CIR | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900771726 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 85 W COMBS RD | ||||||||
| Address2: | SUITE 109 | ||||||||
| City: | SAN TAN VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851409105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808829105 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2013 | ||||||||
| LastUpdateDate: | 12/06/2013 | ||||||||
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| AuthorizedOfficialLastName: | ALFONSO | ||||||||
| AuthorizedOfficialFirstName: | NATHALIE | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4808829105 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AFC OF QUEEN CREEK, PLLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | AP4940 | AZ | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.