Basic Information
| Provider Information | |||||||||
| NPI: | 1366854721 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CBD HEALTHCARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60264 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850820264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028895833 | ||||||||
| FaxNumber: | 6028895834 | ||||||||
| Practice Location | |||||||||
| Address1: | 4540 E BASELINE RD | ||||||||
| Address2: | #105 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852064613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028895833 | ||||||||
| FaxNumber: | 6028895834 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2014 | ||||||||
| LastUpdateDate: | 05/22/2014 | ||||||||
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| AuthorizedOfficialLastName: | DEFRIES | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6028895833 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | AZ | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 207ZP0102X | AZ | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 171M00000X | AZ | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 363LF0000X | AZ | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.