Healthcare Provider Details

I. General information

NPI: 1790256089
Provider Name (Legal Business Name): AZ NEURORECOVERY TREATMENT INNOVATION CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2018
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2812 N NORWALK STE 10-119
MESA AZ
85215-1148
US

IV. Provider business mailing address

2812 N NORWALK STE 10-119
MESA AZ
85215-1148
US

V. Phone/Fax

Practice location:
  • Phone: 480-621-8200
  • Fax: 480-621-8283
Mailing address:
  • Phone: 480-621-8200
  • Fax: 480-621-8283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. MELANIE ALARCIO
Title or Position: PEDIATRIC NEUROLOGIST/PARTNER
Credential: MD
Phone: 480-621-8200