=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376714253
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTH CENTERS OF ARIZONA, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2008
-----------------------------------------------------
Last Update Date | 05/05/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 235 E. WARNER RD B-104
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85296-2972
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-633-3540
-----------------------------------------------------
Fax | 480-633-5605
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 235 E. WARNER RD B-104
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85296-2972
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-633-3540
-----------------------------------------------------
Fax | 480-633-5605
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS MANAGER
-----------------------------------------------------
Name | BRANDON ROBERT CARROLL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-633-3540
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 6795
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------