Healthcare Provider Details

I. General information

NPI: 1770154767
Provider Name (Legal Business Name): CARDIOVASCULAR LAB OF ARIZONA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16638 N 90TH ST STE 101
SCOTTSDALE AZ
85260-1539
US

IV. Provider business mailing address

16638 N 90TH ST STE 101
SCOTTSDALE AZ
85260-1539
US

V. Phone/Fax

Practice location:
  • Phone: 480-747-6532
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: ILENE KLEIN
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 480-747-6532