Provider Demographics
NPI:1508405341
Name:SHEA OUTPATIENT TREATMENT CENTER
Entity Type:Organization
Organization Name:SHEA OUTPATIENT TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-544-6432
Mailing Address - Street 1:8952 E DESERT COVE AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-6776
Mailing Address - Country:US
Mailing Address - Phone:480-935-0990
Mailing Address - Fax:
Practice Address - Street 1:8952 E DESERT COVE AVE STE 103
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-6776
Practice Address - Country:US
Practice Address - Phone:480-935-0990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-26
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain