=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447439195
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARIZONA STATE UNIVERSITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2007
-----------------------------------------------------
Last Update Date | 08/05/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3225 N CIVIC CENTER PLZ SUITE 10
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85251-6919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-884-1717
-----------------------------------------------------
Fax | 480-884-1711
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 N 3RD ST SUITE 155
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85004-2135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-496-0893
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSOCIATE DEAN
-----------------------------------------------------
Name | DR. DENISE GIANNASCOLI LINK
-----------------------------------------------------
Credential | DNSC
-----------------------------------------------------
Telephone | 602-496-0893
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | OTC 4747
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------