Healthcare Provider Details

I. General information

NPI: 1750686614
Provider Name (Legal Business Name): GREATER PHOENIX COLLABORATIVE CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2011
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8041 N BLACK CANYON HWY
PHOENIX AZ
85021-4876
US

IV. Provider business mailing address

PO BOX 35380 MEDICAL STAFF- CREDENTIALING DEPT.
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 602-249-0115
  • Fax:
Mailing address:
  • Phone: 702-579-3253
  • Fax: 702-304-7451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberOTC 4998
License Number StateAZ

VIII. Authorized Official

Name: EMILY CASTILLO
Title or Position: REGIONAL MANAGER
Credential:
Phone: 702-480-2550