=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205208865
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED DIAGNOSTIC & SURGICAL RECOVERY INSTITUTE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2015
-----------------------------------------------------
Last Update Date | 10/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2155 E CONFERENCE DR SUITE 110
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85284-2604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-788-3107
-----------------------------------------------------
Fax | 480-436-6676
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2155 E CONFERENCE DR SUITE 110
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85284-2604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-788-3107
-----------------------------------------------------
Fax | 480-436-6676
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. H. RANDALL CRAIG
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 480-788-3107
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR1100X
-----------------------------------------------------
Taxonomy Name | Research Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QR0800X
-----------------------------------------------------
Taxonomy Name | Recovery Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------