Healthcare Provider Details

I. General information

NPI: 1578028684
Provider Name (Legal Business Name): CAVE CREEK CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 E MOHAWK LN STE 101
PHOENIX AZ
85050-4773
US

IV. Provider business mailing address

15029 N THOMPSON PEAK PKWY # B111-438
SCOTTSDALE AZ
85260-2217
US

V. Phone/Fax

Practice location:
  • Phone: 480-401-1555
  • Fax: 800-930-4408
Mailing address:
  • Phone: 480-401-1555
  • Fax: 800-930-4408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN SHERMAN GILLIAM
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 480-401-1555