Provider Demographics
NPI:1679730493
Name:BILLY CREEK CLINIC
Entity type:Organization
Organization Name:BILLY CREEK CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:LARUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-333-5333
Mailing Address - Street 1:PO BOX 878
Mailing Address - Street 2:
Mailing Address - City:SPRINGERVILLE
Mailing Address - State:AZ
Mailing Address - Zip Code:85938-0878
Mailing Address - Country:US
Mailing Address - Phone:928-333-5333
Mailing Address - Fax:928-333-5100
Practice Address - Street 1:43 W WHITE MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-7002
Practice Address - Country:US
Practice Address - Phone:928-367-4040
Practice Address - Fax:928-367-4042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32794261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care