Provider Demographics
NPI:1366794919
Name:DESERT MOUNTAIN FAMILY MEDICINE P.C.
Entity type:Organization
Organization Name:DESERT MOUNTAIN FAMILY MEDICINE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:L
Authorized Official - Last Name:LUGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-451-9191
Mailing Address - Street 1:11866 E MISSION LN
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85259-5943
Mailing Address - Country:US
Mailing Address - Phone:480-695-3429
Mailing Address - Fax:
Practice Address - Street 1:8428 E SHEA BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-6663
Practice Address - Country:US
Practice Address - Phone:480-451-9191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-06
Last Update Date:2012-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21128261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZB41225Medicare UPIN