MEDICARE: AZTOX, 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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1831644301
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AZTOX, LLC

Provider Business Mailing Address
First Line	:	929 N VAL VISTA DR STE 109-131
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85234-3706
Country	:	US
Telephone Number	:	801-201-4156
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 W GUADALUPE RD STE 314
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85233-3319
Country	:	US
Telephone Number	:	801-201-4156
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. STEVEN BROWN
Credential	:	LCSW
Telephone Number	:	480-632-1345

Provider Enumeration Date	:	08/24/2016
Last Update Date	:	08/24/2016

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