Healthcare Provider Details

I. General information

NPI: 1811556111
Provider Name (Legal Business Name): SOUTHWEST CENTERS FOR REGENERATIVE MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2019
Last Update Date: 06/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2629 N SCOTTSDALE RD STE 100
SCOTTSDALE AZ
85257-1370
US

IV. Provider business mailing address

2629 N SCOTTSDALE RD STE 100
SCOTTSDALE AZ
85257-1370
US

V. Phone/Fax

Practice location:
  • Phone: 602-510-3203
  • Fax: 602-297-6997
Mailing address:
  • Phone: 602-510-3203
  • Fax: 602-297-6997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TINA MANKIN
Title or Position: ADMINISTRATOR
Credential:
Phone: 602-510-3203