Provider Demographics
NPI:1487605481
Name:VAL VISTA LAKES FAMILY MEDICINE, PC
Entity type:Organization
Organization Name:VAL VISTA LAKES FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:
Authorized Official - Last Name:HATFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:480-545-1100
Mailing Address - Street 1:3331 E BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2633
Mailing Address - Country:US
Mailing Address - Phone:480-545-1100
Mailing Address - Fax:480-545-7181
Practice Address - Street 1:3331 E BASELINE RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2633
Practice Address - Country:US
Practice Address - Phone:480-545-1100
Practice Address - Fax:480-545-7181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-14
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZWDBVTMedicare PIN