Healthcare Provider Details

I. General information

NPI: 1164836169
Provider Name (Legal Business Name): ADAMANTIUM INK P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 07/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3954 E WALLER LN
PHOENIX AZ
85050-4916
US

IV. Provider business mailing address

8424 E SHEA BLVD STE 101
SCOTTSDALE AZ
85260-6662
US

V. Phone/Fax

Practice location:
  • Phone: 713-791-4931
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD47798
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberMD47798
License Number StateAZ

VIII. Authorized Official

Name: DR. BRIAN L MARASIGAN
Title or Position: PRESIDENT AND DIRECTOR
Credential: M.D.
Phone: 713-791-4931