1639595754 NPI number — PASSPORT HEALTH HOLDINGS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639595754 NPI number — PASSPORT HEALTH HOLDINGS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PASSPORT HEALTH HOLDINGS, 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:
PASSPORT HEALTH
Provider Other Organization Name Type Code:
3
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:
1639595754
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8324 E HARTFORD DR
Provider Second Line Business Mailing Address:
#200
Provider Business Mailing Address City Name:
SCOTTSDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85255
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-909-6551
Provider Business Mailing Address Fax Number:
480-383-6567

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
118 HUXLEY RD STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37922-3183
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-358-8648
Provider Business Practice Location Address Fax Number:
877-877-8675
Provider Enumeration Date:
03/13/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SHACKELL
Authorized Official First Name:
DOUG
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF FINANCE
Authorized Official Telephone Number:
480-646-9024

Provider Taxonomy Codes

  • Taxonomy code: 2083P0901X , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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