Healthcare Provider Details

I. General information

NPI: 1992547616
Provider Name (Legal Business Name): AZ SKIN CANCER TREATMENT CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2024
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14545 W GRAND AVE # A-106
SURPRISE AZ
85374-7278
US

IV. Provider business mailing address

6535 N ARIZONA BILTMORE CIR
PHOENIX AZ
85016-8907
US

V. Phone/Fax

Practice location:
  • Phone: 602-616-6643
  • Fax:
Mailing address:
  • Phone: 602-616-6643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MIMI ROCKEL
Title or Position: OFFICE MANAGER
Credential:
Phone: 602-616-6643