Provider Demographics
NPI:1679059984
Name:PREMIER REGENERATIVE CENTERS OF ARIZONA, PLLC
Entity Type:Organization
Organization Name:PREMIER REGENERATIVE CENTERS OF ARIZONA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, RN
Authorized Official - Phone:602-510-3203
Mailing Address - Street 1:2629 N SCOTTSDALE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85257-1370
Mailing Address - Country:US
Mailing Address - Phone:602-510-3203
Mailing Address - Fax:602-297-6997
Practice Address - Street 1:2629 N SCOTTSDALE RD STE 100
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85257
Practice Address - Country:US
Practice Address - Phone:602-510-3203
Practice Address - Fax:602-297-6997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-19
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Multi-Specialty