Healthcare Provider Details

I. General information

NPI: 1386088904
Provider Name (Legal Business Name): ANGEL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2013
Last Update Date: 05/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4515 S MCCLINTOCK DR #120
TEMPE AZ
85282-7376
US

IV. Provider business mailing address

PO BOX 10548
SCOTTSDALE AZ
85271-0548
US

V. Phone/Fax

Practice location:
  • Phone: 602-852-0200
  • Fax: 602-852-0381
Mailing address:
  • Phone: 602-852-0200
  • Fax: 602-852-0381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateAZ

VIII. Authorized Official

Name: MURALI TALLURI
Title or Position: OWNER
Credential: MD
Phone: 602-852-0200