MEDICARE: CARLOS PENNIX

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1295409472
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLOS PENNIX

Provider Business Mailing Address
First Line	:	1616 E INDIAN SCHOOL RD STE 225
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-8613
Country	:	US
Telephone Number	:	773-263-3010
Fax Number	:

Provider Business Practice Location Address
First Line	:	1616 E INDIAN SCHOOL RD STE 225
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-8613
Country	:	US
Telephone Number	:	773-263-3010
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2021
Last Update Date	:	09/10/2021

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Directions to “ CARLOS PENNIX ” Practice Location

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