Healthcare Provider Details

I. General information

NPI: 1356813091
Provider Name (Legal Business Name): PHC AZ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2018
Last Update Date: 12/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9318 N 95TH WAY STE A-205
SCOTTSDALE AZ
85258-5537
US

IV. Provider business mailing address

9318 N 95TH WAY STE A-205
SCOTTSDALE AZ
85258-5537
US

V. Phone/Fax

Practice location:
  • Phone: 480-299-7442
  • Fax:
Mailing address:
  • Phone: 480-299-7442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: JOHN GRAKO
Title or Position: OWNER
Credential:
Phone: 480-299-7442