Healthcare Provider Details

I. General information

NPI: 1427101377
Provider Name (Legal Business Name): PHOENIX INDIAN MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4212 N 16TH ST
PHOENIX AZ
85016-5319
US

IV. Provider business mailing address

1244 E BETHANY HOME RD 36-A
PHOENIX AZ
85014-2043
US

V. Phone/Fax

Practice location:
  • Phone: 602-248-4194
  • Fax: 602-200-5381
Mailing address:
  • Phone: 602-266-2281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN051810
License Number StateAZ

VIII. Authorized Official

Name: MR. JUAN J. LOPEZ
Title or Position: PUBLIC HEALTH NURSE
Credential: REGISTERED NURSE
Phone: 602-248-4194