Healthcare Provider Details

I. General information

NPI: 1952572240
Provider Name (Legal Business Name): DIOCESAN COUNCIL OF THE SOCIETY OF ST. VINCENT DE PAUL DIOCESE OF PHX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2008
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W WATKINS RD
PHOENIX AZ
85003-2830
US

IV. Provider business mailing address

PO BOX 13600
PHOENIX AZ
85002-3600
US

V. Phone/Fax

Practice location:
  • Phone: 602-261-6825
  • Fax:
Mailing address:
  • Phone: 602-261-6825
  • Fax: 602-261-6816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License NumberOTC 0669
License Number StateAZ

VIII. Authorized Official

Name: JANICE ERTL
Title or Position: CLINIC DIRECTOR
Credential: RN, MHSA
Phone: 602-261-6880