Healthcare Provider Details

I. General information

NPI: 1376923680
Provider Name (Legal Business Name): INNOVATIVE NEUROPATHY TREATMENT INSTITUTE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2015
Last Update Date: 09/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16601 N 40TH ST SUITE 110
PHOENIX AZ
85032-3345
US

IV. Provider business mailing address

16601 N 40TH ST SUITE 110
PHOENIX AZ
85032-3345
US

V. Phone/Fax

Practice location:
  • Phone: 480-478-0780
  • Fax: 480-478-0655
Mailing address:
  • Phone: 480-478-4780
  • Fax: 480-478-0655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: MS. SUSAN DOHERTY
Title or Position: MANAGING PARTNER
Credential:
Phone: 313-549-0430