Healthcare Provider Details

I. General information

NPI: 1134615453
Provider Name (Legal Business Name): ARROWHEAD INTERVENTIONAL TREATMENT CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2018
Last Update Date: 06/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

PO BOX 11180
TEMPE AZ
85284-0020
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 Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number8494
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHAWN VIGNEAU
Title or Position: SOLE MBR
Credential:
Phone: 480-566-9755