Healthcare Provider Details

I. General information

NPI: 1659041580
Provider Name (Legal Business Name): COMMUNITY PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2021
Last Update Date: 12/22/2021
Certification Date: 12/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13624 W CAMINO DEL SOL STE 150
SUN CITY WEST AZ
85375-3405
US

IV. Provider business mailing address

12409 W INDIAN SCHOOL RD STE A108
AVONDALE AZ
85392-9503
US

V. Phone/Fax

Practice location:
  • Phone: 623-328-7087
  • Fax: 623-218-1337
Mailing address:
  • Phone: 623-328-7087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. AZIZ MALLIK
Title or Position: MANAGING PARTNER
Credential:
Phone: 623-328-7087