Healthcare Provider Details

I. General information

NPI: 1255768990
Provider Name (Legal Business Name): ARIZNA MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2013
Last Update Date: 09/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1847 W HEATHERBRAE DR
PHOENIX AZ
85015-4764
US

IV. Provider business mailing address

1847 W HEATHERBRAE DR
PHOENIX AZ
85015-4764
US

V. Phone/Fax

Practice location:
  • Phone: 602-274-2100
  • Fax: 602-535-3166
Mailing address:
  • Phone: 602-274-2100
  • Fax: 602-535-3166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number48412
License Number StateAZ

VIII. Authorized Official

Name: ROXANA CHENO
Title or Position: OFFICE MANAGER
Credential:
Phone: 602-274-2100