Healthcare Provider Details

I. General information

NPI: 1366116014
Provider Name (Legal Business Name): INTREPID OF THE GRAND CANYON, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2021
Last Update Date: 08/05/2021
Certification Date: 08/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 E RIVER RD STE 110
TUCSON AZ
85718-6595
US

IV. Provider business mailing address

3220 KELLER SPRINGS RD STE 108
CARROLLTON TX
75006-5911
US

V. Phone/Fax

Practice location:
  • Phone: 520-873-9302
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT PARKER
Title or Position: CHIEF COMPLIANCE OFFICER
Credential: CCO
Phone: 214-445-3750