Healthcare Provider Details

I. General information

NPI: 1215430269
Provider Name (Legal Business Name): FIRST IMAGE PRENATAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2018
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10555 N 58TH DR
GLENDALE AZ
85302-1360
US

IV. Provider business mailing address

10555 N 58TH DR
GLENDALE AZ
85302-1360
US

V. Phone/Fax

Practice location:
  • Phone: 480-242-3057
  • Fax:
Mailing address:
  • Phone: 602-508-3340
  • Fax: 602-381-6351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINE REYES
Title or Position: COO
Credential:
Phone: 602-508-3340