Basic Information
| Provider Information | |||||||||
| NPI: | 1568965697 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMPREHENSIVE INTERVENTIONAL CARE CENTERS, PLLC | ||||||||
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| OtherOrganizationName: | COMPREHENSIVE INTERVENTIONAL CARE CENTERS, PLLC - UTAH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4001 E BASELINE RD STE 107 | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852342744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803747354 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5343 S WOODROW ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | MURRAY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841075885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8018102999 | ||||||||
| FaxNumber: | 8013969157 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2018 | ||||||||
| LastUpdateDate: | 10/26/2021 | ||||||||
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| AuthorizedOfficialLastName: | BRENNAN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 5203226274 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMPREHENSIVE INTERVENTIONAL CARE CENTERS, PLLC | ||||||||
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| NPICertificationDate: | 10/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.