Provider Demographics
NPI:1396900122
Name:ORACLE HEALTHCARE
Entity type:Organization
Organization Name:ORACLE HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-649-6477
Mailing Address - Street 1:PO BOX 1270
Mailing Address - Street 2:
Mailing Address - City:CLARKDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:86324-1270
Mailing Address - Country:US
Mailing Address - Phone:928-649-6477
Mailing Address - Fax:928-649-2719
Practice Address - Street 1:348 S MAIN ST
Practice Address - Street 2:STE 1
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322-7155
Practice Address - Country:US
Practice Address - Phone:928-649-6477
Practice Address - Fax:928-649-2719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-21
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ124709Medicare PIN