Provider Demographics
NPI:1285784082
Name:SEASIDE SANCTUARY CLINIC LLC
Entity type:Organization
Organization Name:SEASIDE SANCTUARY CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:C
Authorized Official - Last Name:MEADOWS
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:361-463-1353
Mailing Address - Street 1:2401 W ROUTE 66
Mailing Address - Street 2:#24
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-8761
Mailing Address - Country:US
Mailing Address - Phone:361-463-1353
Mailing Address - Fax:215-261-0666
Practice Address - Street 1:2401 W ROUTE 66
Practice Address - Street 2:#24
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-8761
Practice Address - Country:US
Practice Address - Phone:361-463-1353
Practice Address - Fax:215-261-0666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6250174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0033LTOtherBCBS
TX0033LTOtherBCBS