1063167104 NPI number — EMBRY TESTING AND VACCINES OF HAWAII LLC

Table of content: (NPI 1063167104)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063167104 NPI number — EMBRY TESTING AND VACCINES OF HAWAII LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMBRY TESTING AND VACCINES OF HAWAII 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:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1063167104
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3370 N HAYDEN RD # 123215
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCOTTSDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85251-6632
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4717 E HILTON AVE STE 250
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85034-6400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-376-2175
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/17/2022

Additional Information

Authorized Official

Authorized Official Last Name:
FUQUA
Authorized Official First Name:
MAKESHA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF RCM
Authorized Official Telephone Number:
480-801-5783

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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