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General NPI Number Information
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NPI Number | 1639686546
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Entity Type | Organization
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Legal Business Name | DESERT FOUNTAIN MEDICAL, PLLC
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Dates
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Enumeration Date | 01/02/2018
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Last Update Date | 01/02/2018
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Provider Practice Location Address
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Address Line | 17100 E SHEA BLVD STE 320
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City | FOUNTAIN HILLS
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State | AZ
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Zip | 85268-6654
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Country | US
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Telephone | 480-816-8300
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Fax |
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Provider Business Mailing Address
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Address Line | 17100 E SHEA BLVD STE 320
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City | FOUNTAIN HILLS
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State | AZ
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Zip | 85268-6654
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CLINIC DIRECTOR
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Name | GRANT ANDRES
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Credential |
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Telephone | 480-816-8300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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