Healthcare Provider Details

I. General information

NPI: 1174073837
Provider Name (Legal Business Name): CASPIAN GLEAM MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 10/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3130 STILLWATER DRIVE, SUITE B
PRESCOTT AZ
86305
US

IV. Provider business mailing address

3270 ROSE LN
PRESCOTT AZ
86305-3744
US

V. Phone/Fax

Practice location:
  • Phone: 801-884-9687
  • Fax:
Mailing address:
  • Phone: 801-884-9687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: FARBOD MISAGHIAN
Title or Position: OWNER
Credential:
Phone: 801-884-9687