Healthcare Provider Details

I. General information

NPI: 1871085902
Provider Name (Legal Business Name): OCOTILLO TREATMENT CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 01/02/2020
Certification Date: 01/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3645 S ROME ST STE 204
GILBERT AZ
85297-7338
US

IV. Provider business mailing address

3645 S ROME ST STE 204
GILBERT AZ
85297-7338
US

V. Phone/Fax

Practice location:
  • Phone: 480-771-4400
  • Fax:
Mailing address:
  • Phone: 480-771-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TAICHA L MALDONADO
Title or Position: MANAGER
Credential: MANAGER
Phone: 480-441-7700