MEDICARE: UPLIFTING LIVES CLINIC OF ARIZONA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center
2	343900000X	Non-emergency Medical Transport (VAN)
3	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1841683943
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UPLIFTING LIVES CLINIC OF ARIZONA, LLC

Provider Business Mailing Address
First Line	:	5150 N 99TH AVE
Second Line	:	APT. 1097
City	:	GLENDALE
State	:	AZ
Zip	:	85305-3001
Country	:	US
Telephone Number	:	602-670-6077
Fax Number	:

Provider Business Practice Location Address
First Line	:	5150 N 99TH AVE
Second Line	:	APT. 1097
City	:	GLENDALE
State	:	AZ
Zip	:	85305-3001
Country	:	US
Telephone Number	:	602-670-6077
Fax Number	:

Authorized Official
Title or Position	:	OWNER/CLINICAL DIRECTOR
Name	:	MS. SHANNON CAROLYN PHILLIPS
Credential	:
Telephone Number	:	602-670-6077

Provider Enumeration Date	:	03/13/2015
Last Update Date	:	03/13/2015

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