Basic Information
| Provider Information | |||||||||
| NPI: | 1619172004 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY MEDICAL SERVICES IV LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3825 N 24TH ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850166512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022488886 | ||||||||
| FaxNumber: | 6022488999 | ||||||||
| Practice Location | |||||||||
| Address1: | 3825 N 24TH ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850166512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022488886 | ||||||||
| FaxNumber: | 6022488999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2007 | ||||||||
| LastUpdateDate: | 06/25/2009 | ||||||||
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| AuthorizedOfficialLastName: | TORRES | ||||||||
| AuthorizedOfficialFirstName: | KEELY | ||||||||
| AuthorizedOfficialMiddleName: | N. | ||||||||
| AuthorizedOfficialTitleorPosition: | QUALITY IMPROVEMENT | ||||||||
| AuthorizedOfficialTelephone: | 6022488886 | ||||||||
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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 | 343900000X | BH-2701 | AZ | Y | Transportation Services | Non-emergency Medical Transport (VAN) |
ID Information
| ID | Type | State | Issuer | Description | 961898 | 05 | AZ | MEDICAID |