Healthcare Provider Details

I. General information

NPI: 1619489176
Provider Name (Legal Business Name): CAS MEDICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2017
Last Update Date: 10/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4619 N 24TH ST
PHOENIX AZ
85016-5203
US

IV. Provider business mailing address

4619 N 24TH ST
PHOENIX AZ
85016-5203
US

V. Phone/Fax

Practice location:
  • Phone: 602-956-0111
  • Fax: 602-956-6789
Mailing address:
  • Phone: 602-956-0111
  • Fax: 602-956-6789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP8549
License Number StateAZ

VIII. Authorized Official

Name: VICKI A VEGA
Title or Position: MANAGER
Credential:
Phone: 602-956-0111