Provider Demographics
NPI:1033128293
Name:CAMELBACK WEST MEDICAL CLINIC
Entity Type:Organization
Organization Name:CAMELBACK WEST MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NPMMLLC
Authorized Official - Prefix:MRS
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:ETHEL
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:623-337-3318
Mailing Address - Street 1:5630 W CAMELBACK RD
Mailing Address - Street 2:SUITE105
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-7443
Mailing Address - Country:US
Mailing Address - Phone:623-337-3318
Mailing Address - Fax:623-872-9704
Practice Address - Street 1:5630 W CAMELBACK RD
Practice Address - Street 2:SUITE105
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-7443
Practice Address - Country:US
Practice Address - Phone:623-337-3318
Practice Address - Fax:623-872-9704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261Q00000X261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ469967Medicare UPIN