Healthcare Provider Details

I. General information

NPI: 1265336127
Provider Name (Legal Business Name): PULCREX MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6262 E BROADWAY RD STE 106
MESA AZ
85206-6101
US

IV. Provider business mailing address

6262 E BROADWAY RD STE 106
MESA AZ
85206-6101
US

V. Phone/Fax

Practice location:
  • Phone: 832-267-8165
  • Fax:
Mailing address:
  • Phone: 832-267-8165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. CHIKAODI BANOR
Title or Position: MEDICAL DIRECTOR
Credential: DNP
Phone: 713-355-0426