Basic Information
| Provider Information | |||||||||
| NPI: | 1821432501 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AFC OF QUEEN CREEK, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1839 S ALMA SCHOOL RD | ||||||||
| Address2: | STE 354 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852103028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807262287 | ||||||||
| FaxNumber: | 8883169272 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 W COMBS RD | ||||||||
| Address2: | STE 109 | ||||||||
| City: | SAN TAN VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851409105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808829105 | ||||||||
| FaxNumber: | 4804585833 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2013 | ||||||||
| LastUpdateDate: | 04/24/2013 | ||||||||
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| AuthorizedOfficialLastName: | BOLINE | ||||||||
| AuthorizedOfficialFirstName: | URISSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDNETIALING MGR | ||||||||
| AuthorizedOfficialTelephone: | 4807262287 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.