Healthcare Provider Details

I. General information

NPI: 1841538071
Provider Name (Legal Business Name): PHOENIX VA HEALTHCARE SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2013
Last Update Date: 03/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 S 12TH AVE
PHOENIX AZ
85007-3101
US

IV. Provider business mailing address

650 E INDIAN SCHOOL RD
PHOENIX AZ
85012-1839
US

V. Phone/Fax

Practice location:
  • Phone: 602-510-7971
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License NumberLMSW-13456
License Number StateAZ

VIII. Authorized Official

Name: MR. JOHN NELSON MCVADE JR.
Title or Position: SOCIAL WORKER
Credential: LMSW
Phone: 602-510-7971