Healthcare Provider Details

I. General information

NPI: 1013151323
Provider Name (Legal Business Name): JOHN C LINCOLN , LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2009
Last Update Date: 06/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5859 W TALAVI BLVD SUITE 165
GLENDALE AZ
85306-1869
US

IV. Provider business mailing address

5859 W TALAVI BLVD SUITE 165
GLENDALE AZ
85306-1869
US

V. Phone/Fax

Practice location:
  • Phone: 602-548-7800
  • Fax: 602-548-0006
Mailing address:
  • Phone: 602-548-7800
  • Fax: 602-548-0006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number3010
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3316
License Number StateAZ

VIII. Authorized Official

Name: MR. NATHAN ANSPACH
Title or Position: CEO
Credential:
Phone: 602-548-7800