Provider Demographics
NPI:1386088904
Name:ANGEL CLINIC LLC
Entity type:Organization
Organization Name:ANGEL CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MURALI
Authorized Official - Middle Name:
Authorized Official - Last Name:TALLURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-852-0200
Mailing Address - Street 1:PO BOX 10548
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85271-0548
Mailing Address - Country:US
Mailing Address - Phone:602-852-0200
Mailing Address - Fax:602-852-0381
Practice Address - Street 1:4515 S MCCLINTOCK DR
Practice Address - Street 2:#120
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7376
Practice Address - Country:US
Practice Address - Phone:602-852-0200
Practice Address - Fax:602-852-0381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-25
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261QH0100X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty