Basic Information
| Provider Information | |||||||||
| NPI: | 1962177022 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EMBRY TESTING AND VACCINE SERVICES OF ARIZONA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 64173 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850824173 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3350 S PRICE RD | ||||||||
| Address2: | |||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852827528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803762170 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2021 | ||||||||
| LastUpdateDate: | 09/06/2022 | ||||||||
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| AuthorizedOfficialLastName: | EMBRY | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4803762170 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CEO | ||||||||
| NPICertificationDate: | 09/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.