Basic Information
| Provider Information | |||||||||
| NPI: | 1710470802 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AZ SPORTS AND SPINE CENTER , LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3717 SOUTH HIGLEY ROAD | ||||||||
| Address2: | SUITE 114 PMB 298 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024817369 | ||||||||
| FaxNumber: | 4805271586 | ||||||||
| Practice Location | |||||||||
| Address1: | 604 W WARNER RD STE A | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852252900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024817369 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2018 | ||||||||
| LastUpdateDate: | 09/28/2018 | ||||||||
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| AuthorizedOfficialLastName: | BECKER | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6024817369 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.