MEDICARE: RED ROCK WELLNESS CARE CENTER, 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	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1770939092
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RED ROCK WELLNESS CARE CENTER, LLC

Provider Business Mailing Address
First Line	:	PO BOX 29650
Second Line	:	DEPT# 880122
City	:	PHOENIX
State	:	AZ
Zip	:	85038-9650
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	13951 W MEEKER BLVD
Second Line	:	ROOM 1
City	:	SUN CITY WEST
State	:	AZ
Zip	:	85375-4424
Country	:	US
Telephone Number	:	602-833-8452
Fax Number	:	480-718-8839

Authorized Official
Title or Position	:	CHIEF ADMINISTRATIVE OFFICER
Name	:	MR. EDWARD ROUSSEAU
Credential	:
Telephone Number	:	772-266-7682

Provider Enumeration Date	:	05/05/2016
Last Update Date	:	08/09/2018

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