Healthcare Provider Details

I. General information

NPI: 1841731932
Provider Name (Legal Business Name): METRO OTC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2017
Last Update Date: 08/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10046 N METRO PKWY W SUITE 115
PHOENIX AZ
85051
US

IV. Provider business mailing address

10046 N METRO PKWY W SUITE 115
PHOENIX AZ
85051-1437
US

V. Phone/Fax

Practice location:
  • Phone: 602-674-5515
  • Fax: 602-674-3029
Mailing address:
  • Phone: 602-674-5515
  • Fax: 602-674-3029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. CHALLEN WAYCHOFF III
Title or Position: COO/MANAGER
Credential:
Phone: 760-486-9634