=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457153306
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INJX BAR LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2025
-----------------------------------------------------
Last Update Date | 03/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10200 W HAPPY VALLEY PKWY STE 125
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85383-2878
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-737-5076
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10200 W HAPPY VALLEY PKWY STE 125
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85383-2878
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-737-5076
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER / WELLNESS DIRECTOR
-----------------------------------------------------
Name | CARY ROBERT COLE
-----------------------------------------------------
Credential | FNP-C
-----------------------------------------------------
Telephone | 480-737-5076
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------