Healthcare Provider Details

I. General information

NPI: 1245862275
Provider Name (Legal Business Name): GLENDALE INTERVENTIONAL TREATMENT CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2020
Last Update Date: 02/07/2020
Certification Date: 02/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6320 W UNION HILLS DR STE 1400B
GLENDALE AZ
85308-1061
US

IV. Provider business mailing address

6320 W UNION HILLS DR STE 1400B
GLENDALE AZ
85308-1061
US

V. Phone/Fax

Practice location:
  • Phone: 623-688-5400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHAWN VIGNEAU
Title or Position: SOLE MEMBER
Credential: DC
Phone: 480-930-4018