Healthcare Provider Details

I. General information

NPI: 1871206821
Provider Name (Legal Business Name): ADVANCED MINIMALLY INVASIVE SURGICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2023
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14804 N CAVE CREEK RD STE 200
PHOENIX AZ
85032-4945
US

IV. Provider business mailing address

202 E EARLL DR STE 360
PHOENIX AZ
85012-2677
US

V. Phone/Fax

Practice location:
  • Phone: 480-240-5613
  • Fax:
Mailing address:
  • Phone: 480-240-5613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: KIUP ALEXANDER KIM
Title or Position: OWNER
Credential:
Phone: 480-323-6072