Provider Demographics
NPI:1467079020
Name:ARIZONA STATE UNIVERSITY
Entity Type:Organization
Organization Name:ARIZONA STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:C
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-727-5594
Mailing Address - Street 1:1475 N SCOTTSDALE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85257-3538
Mailing Address - Country:US
Mailing Address - Phone:480-965-4544
Mailing Address - Fax:480-884-1888
Practice Address - Street 1:1001 S MCALLISTER AVE
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-2115
Practice Address - Country:US
Practice Address - Phone:480-727-8322
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARIZONA STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory