Healthcare Provider Details

I. General information

NPI: 1720497258
Provider Name (Legal Business Name): ARIZONA GRAND MEDICAL CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2014
Last Update Date: 08/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3773 CROSSINGS DR SUITE B
PRESCOTT AZ
86305-7140
US

IV. Provider business mailing address

PO BOX 47729
PHOENIX AZ
85068-7729
US

V. Phone/Fax

Practice location:
  • Phone: 602-550-4065
  • Fax: 623-934-5603
Mailing address:
  • Phone: 602-550-4065
  • Fax: 623-934-5603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SATWANT BHOWRA
Title or Position: CFO
Credential:
Phone: 602-550-4065