Healthcare Provider Details

I. General information

NPI: 1457801300
Provider Name (Legal Business Name): ELITE ENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2016
Last Update Date: 01/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2340 E BEARDSLEY RD SUITE 260
PHOENIX AZ
85024-1285
US

IV. Provider business mailing address

2340 E BEARDSLEY RD SUITE 260
PHOENIX AZ
85024-1285
US

V. Phone/Fax

Practice location:
  • Phone: 602-802-8240
  • Fax: 602-802-8245
Mailing address:
  • Phone: 602-802-8240
  • Fax: 602-802-8245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: LUIS F VAZQUEZ MD
Title or Position: MANAGER
Credential: JANNET DE CARDENAS
Phone: 602-863-1716