Healthcare Provider Details

I. General information

NPI: 1679727531
Provider Name (Legal Business Name): ADVANCED CARDIOLOGY DIAGNOSTIC CENTERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2008
Last Update Date: 05/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W GLENDALE AVE SUITE 208
PHOENIX AZ
85021-7677
US

IV. Provider business mailing address

6036 N 19TH AVE SUITE 405
PHOENIX AZ
85015-2106
US

V. Phone/Fax

Practice location:
  • Phone: 602-424-1868
  • Fax: 602-424-1874
Mailing address:
  • Phone: 602-424-4450
  • Fax: 602-424-4451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number32892
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number32892
License Number StateAZ

VIII. Authorized Official

Name: JIM BOEHLE
Title or Position: PRESIDENT
Credential:
Phone: 602-424-1868