Basic Information
| Provider Information | |||||||||
| NPI: | 1225337207 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GOLD CANYON FAMILY PRACTICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6820 S KINGS RANCH RD STE 130 | ||||||||
| Address2: | |||||||||
| City: | GOLD CANYON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851182959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803471321 | ||||||||
| FaxNumber: | 4809823692 | ||||||||
| Practice Location | |||||||||
| Address1: | 6820 S KINGS RANCH RD STE 130 | ||||||||
| Address2: | |||||||||
| City: | GOLD CANYON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851182959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803471321 | ||||||||
| FaxNumber: | 4809823692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2011 | ||||||||
| LastUpdateDate: | 09/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | RUTKOWSKI | ||||||||
| AuthorizedOfficialFirstName: | DAITON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4809823691 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.