Healthcare Provider Details

I. General information

NPI: 1528809589
Provider Name (Legal Business Name): ARIZONA FAMILY TRAUMA CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15901 W WADDELL RD APT 1124
SURPRISE AZ
85379-0023
US

IV. Provider business mailing address

15901 W WADDELL RD APT 1124
SURPRISE AZ
85379-0023
US

V. Phone/Fax

Practice location:
  • Phone: 480-318-6688
  • Fax:
Mailing address:
  • Phone: 480-318-6688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: BRIAN TIMOTHY LONGWORTH
Title or Position: MD
Credential:
Phone: 480-318-6688