Basic Information
| Provider Information | |||||||||
| NPI: | 1497260426 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CIRCLE THE CITY | ||||||||
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| OtherOrganizationName: | CIRCLE THE CITY FAMILY HEALTH CENTER, AFTER HOURS CLINIC - LDRC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 W CLARENDON AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850133422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027760776 | ||||||||
| FaxNumber: | 6027050567 | ||||||||
| Practice Location | |||||||||
| Address1: | 1125 W JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850073110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027760776 | ||||||||
| FaxNumber: | 6027050567 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2017 | ||||||||
| LastUpdateDate: | 12/13/2017 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | BRANDON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6027760776 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.