MEDICARE: NCSRV, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2081S0010X	Sports Medicine (Physical Medicine & Rehabilitation) Physician
2	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1093182453
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NCSRV, LLC

Provider Business Mailing Address
First Line	:	7710 W LOWER BUCKEYE RD
Second Line	:	SUITE 115
City	:	PHOENIX
State	:	AZ
Zip	:	85043-3439
Country	:	US
Telephone Number	:	623-776-2225
Fax Number	:	623-776-2299

Provider Business Practice Location Address
First Line	:	7710 W LOWER BUCKEYE RD
Second Line	:	SUITE 115
City	:	PHOENIX
State	:	AZ
Zip	:	85043-3439
Country	:	US
Telephone Number	:	623-776-2225
Fax Number	:	623-776-2299

Authorized Official
Title or Position	:	BILLER
Name	:	MRS. SYLVIA LISA VALENZUELA
Credential	:
Telephone Number	:	623-776-2225

Provider Enumeration Date	:	09/01/2015
Last Update Date	:	09/01/2015

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