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General NPI Number Information
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NPI Number | 1528426806
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Entity Type | Organization
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Legal Business Name | TAZ GLENDALE, LLC
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Dates
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Enumeration Date | 02/02/2016
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Last Update Date | 06/07/2016
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Provider Practice Location Address
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Address Line | 5605 W EUGIE AVE SUITE 111
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City | GLENDALE
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State | AZ
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Zip | 85304-1272
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Country | US
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Telephone | 480-306-8195
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Fax | 480-306-8196
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Provider Business Mailing Address
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Address Line | 5605 W EUGIE AVE SUITE 111
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City | GLENDALE
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State | AZ
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Zip | 85304-1272
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Country | US
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Telephone | 480-306-8195
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Fax | 480-306-8196
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Authorized Official
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Title or Position | COO
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Name | ANDREW M ELLIOTT
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Credential |
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Telephone | 323-369-0069
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State | AZ
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