Healthcare Provider Details

I. General information

NPI: 1811244601
Provider Name (Legal Business Name): 19TH AVENUE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2012
Last Update Date: 08/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1804 W ELLIOT RD
TEMPE AZ
85284-1004
US

IV. Provider business mailing address

PO BOX 32950
PHOENIX AZ
85064-2950
US

V. Phone/Fax

Practice location:
  • Phone: 480-456-0444
  • Fax: 480-456-0449
Mailing address:
  • Phone: 602-275-6110
  • Fax: 602-242-3519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. RENEE L BISKUPSKI
Title or Position: VP OF OPERATIONS
Credential:
Phone: 602-433-1822