Healthcare Provider Details

I. General information

NPI: 1558954784
Provider Name (Legal Business Name): TOTAL VASCULAR CARE CENTER TWO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2021
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13128 N 94TH DR STE 100
PEORIA AZ
85381-4252
US

IV. Provider business mailing address

13128 N 94TH DR STE 100
PEORIA AZ
85381-4252
US

V. Phone/Fax

Practice location:
  • Phone: 623-259-5900
  • Fax: 833-766-3364
Mailing address:
  • Phone: 623-259-5900
  • Fax: 833-766-3364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RICHARD NEVILLE
Title or Position: OWNER
Credential: MD
Phone: 623-259-5900