Healthcare Provider Details

I. General information

NPI: 1972079747
Provider Name (Legal Business Name): INTEGRO HEALTH SYSTEMS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2018
Last Update Date: 12/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 E ORANGEWOOD AVE BLDG C
PHOENIX AZ
85020-5130
US

IV. Provider business mailing address

1501 E ORANGEWOOD AVE
PHOENIX AZ
85020-5130
US

V. Phone/Fax

Practice location:
  • Phone: 602-535-8200
  • Fax: 602-457-2517
Mailing address:
  • Phone: 602-535-8200
  • Fax: 602-457-2517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. MARCO VALERIO CANULLA
Title or Position: FOUNDER AND CHAIRMAN
Credential: MD
Phone: 602-571-6521