Healthcare Provider Details

I. General information

NPI: 1447410048
Provider Name (Legal Business Name): MARICOPA COUNTY D.B.A. MARICOPA COUNTY DEPART
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 02/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1645 E. ROOSEVELT STREET CLINICAL SERVICES
PHOENIX AZ
85006
US

IV. Provider business mailing address

1645 E ROOSEVELT STREET CLINICAL SERVICES
PHOENIX AZ
85006
US

V. Phone/Fax

Practice location:
  • Phone: 608-506-6660
  • Fax: 602-375-0342
Mailing address:
  • Phone: 602-506-6660
  • Fax: 602-372-0342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberOTC3761
License Number StateAZ

VIII. Authorized Official

Name: MR. MAX PORTER
Title or Position: DEPUTY DIRECTOR
Credential:
Phone: 602-506-6641