Healthcare Provider Details

I. General information

NPI: 1407102163
Provider Name (Legal Business Name): 19TH AVENUE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2012
Last Update Date: 07/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3302 W THOMAS RD STE 10
PHOENIX AZ
85017-5605
US

IV. Provider business mailing address

PO BOX 32950
PHOENIX AZ
85064-2950
US

V. Phone/Fax

Practice location:
  • Phone: 602-233-2900
  • Fax: 602-233-3897
Mailing address:
  • Phone: 602-275-6110
  • Fax: 602-242-3519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. RENEE L BISKUPSKI
Title or Position: VP OF OPERATIONS
Credential:
Phone: 602-433-1822