Healthcare Provider Details

I. General information

NPI: 1205533189
Provider Name (Legal Business Name): MR. BROC GIANNI HUTCHINSON III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2023
Last Update Date: 02/13/2023
Certification Date: 02/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5040 E SHEA BLVD STE 164
SCOTTSDALE AZ
85254-4686
US

IV. Provider business mailing address

5040 E SHEA BLVD STE 164
SCOTTSDALE AZ
85254-4686
US

V. Phone/Fax

Practice location:
  • Phone: 678-643-8309
  • Fax:
Mailing address:
  • Phone: 678-643-8309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: