Provider Demographics
NPI:1750686614
Name:GREATER PHOENIX COLLABORATIVE CARE, PC
Entity Type:Organization
Organization Name:GREATER PHOENIX COLLABORATIVE CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-480-2550
Mailing Address - Street 1:PO BOX 35380
Mailing Address - Street 2:MEDICAL STAFF- CREDENTIALING DEPT.
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:702-579-3253
Mailing Address - Fax:702-304-7451
Practice Address - Street 1:8041 N BLACK CANYON HWY
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-4876
Practice Address - Country:US
Practice Address - Phone:602-249-0115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREATER PHOENIX COLLABORATIVE CARE, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-24
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC 4998261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ184835Medicare PIN