Provider Demographics
NPI:1679014765
Name:UPTOWN FACILITY, LLC
Entity Type:Organization
Organization Name:UPTOWN FACILITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAYCHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-486-9634
Mailing Address - Street 1:3724 N 3RD ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2034
Mailing Address - Country:US
Mailing Address - Phone:602-714-8185
Mailing Address - Fax:602-714-8117
Practice Address - Street 1:3724 N 3RD ST
Practice Address - Street 2:SUITE 302
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2034
Practice Address - Country:US
Practice Address - Phone:602-714-8185
Practice Address - Fax:602-714-8117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical