Healthcare Provider Details

I. General information

NPI: 1649440561
Provider Name (Legal Business Name): INFINITE POTENTIAL CENTERS FOR HEALING, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2008
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6124 E DELCOA AVE
SCOTTSDALE AZ
85254-3823
US

IV. Provider business mailing address

6124 E DELCOA AVE
SCOTTSDALE AZ
85254-3823
US

V. Phone/Fax

Practice location:
  • Phone: 480-219-4439
  • Fax: 480-219-4569
Mailing address:
  • Phone: 480-219-4439
  • Fax: 480-219-4569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number5988
License Number StateAZ

VIII. Authorized Official

Name: DR. STEPHANIE MANCUSO
Title or Position: PRESIDENT
Credential: RD, DC, FICPA
Phone: 480-219-4439