Provider Demographics
NPI:1073712998
Name:ZANCAM LLC
Entity type:Organization
Organization Name:ZANCAM LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:JOWAISZAS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:602-418-7031
Mailing Address - Street 1:2253 E HALE ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-4012
Mailing Address - Country:US
Mailing Address - Phone:602-418-7031
Mailing Address - Fax:480-610-9811
Practice Address - Street 1:1919 E MCKELLIPS RD
Practice Address - Street 2:STE. 106
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-2844
Practice Address - Country:US
Practice Address - Phone:602-418-7031
Practice Address - Fax:480-610-9810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2089261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ330040OtherPHCS
AZ0463340OtherBLUE CROSS BLUE SHIELD
AZ101482Medicare UPIN