Basic Information
| Provider Information | |||||||||
| NPI: | 1700471653 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMPREHENSIVE INTERVENTIONAL CARE CENTERS, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 838 W ELLIOT RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852335162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803747354 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10555 N TATUM BLVD STE A101 | ||||||||
| Address2: | |||||||||
| City: | PARADISE VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852531096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029540777 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2021 | ||||||||
| LastUpdateDate: | 03/03/2021 | ||||||||
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| AuthorizedOfficialLastName: | RAINWATER | ||||||||
| AuthorizedOfficialFirstName: | JOEL | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO, CMO | ||||||||
| AuthorizedOfficialTelephone: | 4803747354 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMPREHENSIVE INTERVENTION CARE CENTERS, PLLC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 213ES0103X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0131X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery | 213E00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.