Healthcare Provider Details

I. General information

NPI: 1891850145
Provider Name (Legal Business Name): CACTUS CHILDRENS CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 02/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5940 W UNION HILLS DR SUITE D-100
GLENDALE AZ
85308-1308
US

IV. Provider business mailing address

5940 W UNION HILLS DR SUITE D-100
GLENDALE AZ
85308-1308
US

V. Phone/Fax

Practice location:
  • Phone: 602-978-2500
  • Fax: 602-938-2198
Mailing address:
  • Phone: 602-978-2500
  • Fax: 602-938-2198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number32657
License Number StateAZ

VIII. Authorized Official

Name: MR. JASON D VARGAS
Title or Position: TREASURER/OWNER
Credential: MD
Phone: 602-978-2500