Healthcare Provider Details

I. General information

NPI: 1467508432
Provider Name (Legal Business Name): KACHINA FAMILY PRACTICE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16611 S 40TH ST SUITE 120
PHOENIX AZ
85048
US

IV. Provider business mailing address

16611 S 40TH ST SUITE 120
PHOENIX AZ
85048
US

V. Phone/Fax

Practice location:
  • Phone: 480-706-4100
  • Fax: 480-706-2600
Mailing address:
  • Phone: 480-706-4100
  • Fax: 480-706-2600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JARON JOSEPH FISCHBECK
Title or Position: PRESIDENT
Credential: MD
Phone: 480-706-4100