1174950471 NPI number — SOVEREIGN HEALTH OF PHOENIX, INC.

Table of content: (NPI 1174950471)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174950471 NPI number — SOVEREIGN HEALTH OF PHOENIX, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOVEREIGN HEALTH OF PHOENIX, INC.
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:
1174950471
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5705
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN CLEMENTE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92674-5705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-625-0376
Provider Business Mailing Address Fax Number:
949-390-9899

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 S HEARTHSTONE WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHANDLER
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85226-5010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-625-0376
Provider Business Practice Location Address Fax Number:
949-390-9899
Provider Enumeration Date:
10/01/2013

Additional Information

Authorized Official

Authorized Official Last Name:
GIRSKIS
Authorized Official First Name:
RON
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS OPERATIONS SPECIALIST
Authorized Official Telephone Number:
949-359-8273

Provider Taxonomy Codes

  • Taxonomy code: 320800000X , with the licence number:  2005211229 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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