Provider Demographics
NPI:1801411152
Name:SOUTHWEST IOM PRO LLC
Entity Type:Organization
Organization Name:SOUTHWEST IOM PRO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:S
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-293-3985
Mailing Address - Street 1:6401 E CARON DR
Mailing Address - Street 2:
Mailing Address - City:PARADISE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-1862
Mailing Address - Country:US
Mailing Address - Phone:623-293-3985
Mailing Address - Fax:
Practice Address - Street 1:6401 E CARON DR
Practice Address - Street 2:
Practice Address - City:PARADISE VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85253-1862
Practice Address - Country:US
Practice Address - Phone:623-293-3985
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty