Healthcare Provider Details

I. General information

NPI: 1982142873
Provider Name (Legal Business Name): TEMPE OUTPATIENT TREATMENT CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2017
Last Update Date: 02/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 E WARNER RD STE 103
TEMPE AZ
85284
US

IV. Provider business mailing address

1001 E WARNER RD STE 103
TEMPE AZ
85284
US

V. Phone/Fax

Practice location:
  • Phone: 480-897-3300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEREMY BUCKNER
Title or Position: MBR
Credential: DC
Phone: 480-897-3300