1104045830 NPI number — BROCA HEALTH LLC

Table of content: (NPI 1104045830)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104045830 NPI number — BROCA HEALTH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROCA HEALTH LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104045830
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3941 E CHANDLER BLVD
Provider Second Line Business Mailing Address:
STE. 106-158
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85048-0301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-557-5710
Provider Business Mailing Address Fax Number:
480-557-5712

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1492 S MILL AVE
Provider Second Line Business Practice Location Address:
STE. 114
Provider Business Practice Location Address City Name:
TEMPE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85281-5652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-557-5710
Provider Business Practice Location Address Fax Number:
480-557-5712
Provider Enumeration Date:
04/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CABEZUDO
Authorized Official First Name:
IGNACIO
Authorized Official Middle Name:
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
480-557-5710

Provider Taxonomy Codes

  • Taxonomy code: 302R00000X , with the licence number:  29743 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 825512 . This is a "AETNA GROUP #" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 9656031 . This is a "CIGNA #" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 636293 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1583670 . This is a "UNITED HEALTHCARE #" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 2Z2152 . This is a "HEALTHNET #" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 3267734 . This is a "AETNA PROVIDER #" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 7910494 . This is a "AETNA PIN #" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ0767110 . This is a "BCBSAZ #" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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