Basic Information
| Provider Information | |||||||||
| NPI: | 1073608832 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | METROPOLITAN NEURO BEHAVIORAL INSTITUTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7328 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852167328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804644431 | ||||||||
| FaxNumber: | 4804642338 | ||||||||
| Practice Location | |||||||||
| Address1: | 4055 W CHANDLER BLVD | ||||||||
| Address2: | SUITE #5 | ||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852263700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804644431 | ||||||||
| FaxNumber: | 4804642338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 04/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | AMEZCUA-PATINO | ||||||||
| AuthorizedOfficialFirstName: | LAURO | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4804644431 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 17900 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1659364396 | 01 | AZ | DR'S NPI # | OTHER |