MEDICARE: AFC OF PHOENIX, PLLC

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	332900000X	Non-Pharmacy Dispensing Site	AP5397	AZ

General Provider Information

NPI Number	:	1154740348
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AFC OF PHOENIX, PLLC

Provider Business Mailing Address
First Line	:	2980 N BEVERLY GLEN CIR
Second Line	:	SUITE 301
City	:	LOS ANGELES
State	:	CA
Zip	:	90077-1726
Country	:	US
Telephone Number	:	310-943-4180
Fax Number	:

Provider Business Practice Location Address
First Line	:	2 N CENTRAL AVE
Second Line	:	SUITE 120
City	:	PHOENIX
State	:	AZ
Zip	:	85004-2322
Country	:	US
Telephone Number	:	602-296-4060
Fax Number	:	602-296-4146

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	LISA M. PACE
Credential	:	N.P.
Telephone Number	:	602-296-4060

Provider Enumeration Date	:	04/15/2014
Last Update Date	:	04/15/2014

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