Healthcare Provider Details

I. General information

NPI: 1164660908
Provider Name (Legal Business Name): INFANT CHILD RESEARCH PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2009
Last Update Date: 02/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

INFANT CHILD RESEARCH PROGRAM AT ASU 200 E. CURRY ROAD
TEMPE AZ
85287-0001
US

IV. Provider business mailing address

INFANT CHILD RESEARCH PROGRAM AT ASU PO BOX 871908
TEMPE AZ
85287-0001
US

V. Phone/Fax

Practice location:
  • Phone: 480-965-9396
  • Fax: 480-965-0965
Mailing address:
  • Phone: 480-965-9396
  • Fax: 480-965-0965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. KATHIE SMITH
Title or Position: ADMINISTRATIVE ASSISTANT
Credential:
Phone: 480-965-9396