Healthcare Provider Details

I. General information

NPI: 1093182453
Provider Name (Legal Business Name): NCSRV, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2015
Last Update Date: 09/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7710 W LOWER BUCKEYE RD SUITE 115
PHOENIX AZ
85043-3439
US

IV. Provider business mailing address

7710 W LOWER BUCKEYE RD SUITE 115
PHOENIX AZ
85043-3439
US

V. Phone/Fax

Practice location:
  • Phone: 623-776-2225
  • Fax: 623-776-2299
Mailing address:
  • Phone: 623-776-2225
  • Fax: 623-776-2299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. SYLVIA LISA VALENZUELA
Title or Position: BILLER
Credential:
Phone: 623-776-2225