Provider Demographics
NPI:1124250345
Name:ALT MED CTR LLC
Entity type:Organization
Organization Name:ALT MED CTR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:FONTES
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:602-332-8079
Mailing Address - Street 1:1701 W CAMELBACK RD
Mailing Address - Street 2:STE 150
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015
Mailing Address - Country:US
Mailing Address - Phone:602-332-8079
Mailing Address - Fax:
Practice Address - Street 1:1701 W CAMELBACK RD
Practice Address - Street 2:STE 150
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015
Practice Address - Country:US
Practice Address - Phone:602-332-8079
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-21
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0680171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty