Provider Demographics
NPI:1972806834
Name:DESERT RIDGE URGENT CARE CENTERS
Entity type:Organization
Organization Name:DESERT RIDGE URGENT CARE CENTERS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER / PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:PETTIT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:480-706-0174
Mailing Address - Street 1:16515 S 40TH ST
Mailing Address - Street 2:SUITE 139
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-0558
Mailing Address - Country:US
Mailing Address - Phone:480-706-0174
Mailing Address - Fax:480-706-0117
Practice Address - Street 1:40 S KYRENE RD
Practice Address - Street 2:SUITE 3
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-4675
Practice Address - Country:US
Practice Address - Phone:480-706-0174
Practice Address - Fax:480-706-0117
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DESERT RIDGE URGENT CARE CENTERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3344208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty