MEDICARE: BANNER HEALTH CLINIC

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1750641403
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BANNER HEALTH CLINIC

Provider Business Mailing Address
First Line	:	2901 N CENTRAL AVE STE 160
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85012-2702
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1432 S DOBSON RD STE 402
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85202-4777
Country	:	US
Telephone Number	:	480-412-5550
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	DENNIS LARAWAY
Credential	:
Telephone Number	:	602-747-4000

Provider Enumeration Date	:	05/29/2012
Last Update Date	:	12/28/2021

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Directions to “BANNER HEALTH CLINIC ” Practice Location

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