Healthcare Provider Details

I. General information

NPI: 1811176530
Provider Name (Legal Business Name): CTHVAMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2007
Last Update Date: 10/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 W UTOPIA RD
PHOENIX AZ
85027-4738
US

IV. Provider business mailing address

239 W UTOPIA RD
PHOENIX AZ
85027-4738
US

V. Phone/Fax

Practice location:
  • Phone: 602-277-5551
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number4023
License Number StateAZ

VIII. Authorized Official

Name: MR. MICHAEL LYNN GHIDOTTI
Title or Position: COTA
Credential: COTA/L
Phone: 602-277-5551