Healthcare Provider Details

I. General information

NPI: 1982891115
Provider Name (Legal Business Name): COMPREHENSIVE BREAST CENTER OF ARIZONA, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2007
Last Update Date: 11/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9179 W THUNDERBIRD RD 103
PEORIA AZ
85381-4875
US

IV. Provider business mailing address

9179 W THUNDERBIRD RD 103
PEORIA AZ
85381-4875
US

V. Phone/Fax

Practice location:
  • Phone: 602-374-3440
  • Fax: 602-374-3441
Mailing address:
  • Phone: 602-374-3440
  • Fax: 602-374-3441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4264
License Number StateAZ

VIII. Authorized Official

Name: S BRENDA MOORTHY
Title or Position: PROPRIETOR
Credential: DO
Phone: 602-374-3440