Healthcare Provider Details

I. General information

NPI: 1568965697
Provider Name (Legal Business Name): COMPREHENSIVE INTERVENTIONAL CARE CENTERS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2018
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5343 S WOODROW ST STE 100
MURRAY UT
84107-5885
US

IV. Provider business mailing address

4001 E BASELINE RD STE 107
GILBERT AZ
85234-2744
US

V. Phone/Fax

Practice location:
  • Phone: 801-810-2999
  • Fax: 801-396-9157
Mailing address:
  • Phone: 480-374-7354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN J BRENNAN
Title or Position: CREDENTIALING
Credential:
Phone: 520-322-6274