Provider Demographics
NPI:1811244601
Name:19TH AVENUE CLINIC LLC
Entity type:Organization
Organization Name:19TH AVENUE CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BISKUPSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-433-1822
Mailing Address - Street 1:PO BOX 32950
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85064-2950
Mailing Address - Country:US
Mailing Address - Phone:602-275-6110
Mailing Address - Fax:602-242-3519
Practice Address - Street 1:1804 W ELLIOT RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-1004
Practice Address - Country:US
Practice Address - Phone:480-456-0444
Practice Address - Fax:480-456-0449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care