1962788331 NPI number — A-1 ORTHOPEDIC, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962788331 NPI number — A-1 ORTHOPEDIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
A-1 ORTHOPEDIC, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962788331
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2501 E SOUTHERN AVE
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
TEMPE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85282-7669
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-299-7908
Provider Business Mailing Address Fax Number:
480-835-1021

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2501 E SOUTHERN AVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
TEMPE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85282-7669
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-299-7908
Provider Business Practice Location Address Fax Number:
480-835-1021
Provider Enumeration Date:
10/28/2011

Additional Information

Authorized Official

Authorized Official Last Name:
DIENER
Authorized Official First Name:
HAAGEN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
480-833-0204

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  29248 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 563016 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 65596 . This is a "MEDICARE ID" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ0884660 . This is a "BCBS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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