Healthcare Provider Details

I. General information

NPI: 1518334408
Provider Name (Legal Business Name): PVIM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2015
Last Update Date: 08/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4494 W PEORIA AVE STE 115A
GLENDALE AZ
85302-2020
US

IV. Provider business mailing address

4494 W PEORIA AVE STE 115A
GLENDALE AZ
85302-2020
US

V. Phone/Fax

Practice location:
  • Phone: 623-773-2273
  • Fax:
Mailing address:
  • Phone: 623-773-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number33520
License Number StateAZ

VIII. Authorized Official

Name: DR. RICK M SLOAN
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 623-773-2273