Healthcare Provider Details

I. General information

NPI: 1720359870
Provider Name (Legal Business Name): COMMUNITY CAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2012
Last Update Date: 01/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1254 W BROADWAY RD
MESA AZ
85202-1110
US

IV. Provider business mailing address

1254 W BROADWAY RD
MESA AZ
85202-1110
US

V. Phone/Fax

Practice location:
  • Phone: 480-644-1000
  • Fax:
Mailing address:
  • Phone: 480-644-1000
  • Fax: 480-644-1010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code344600000X
TaxonomyTaxi
License NumberBMF37026
License Number StateAZ

VIII. Authorized Official

Name: MS. DAWN L NOWATZKI
Title or Position: MANAGING MEMBER
Credential: MANAGING MEMBER
Phone: 480-644-1000