1205377736 NPI number — PASSPORT HEALTH HOLDINGS, LLC

Table of content: (NPI 1205377736)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205377736 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:
PPH FRANCHISE HOLDINGS, LLC
Provider Other Organization Name Type Code:
5
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:
1205377736
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/16/2017
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:
STE 200
Provider Business Mailing Address City Name:
SCOTTSDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85255-7801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-358-8648
Provider Business Mailing Address Fax Number:
877-877-6875

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1055 NORTH 300 WEST
Provider Second Line Business Practice Location Address:
STE 416
Provider Business Practice Location Address City Name:
PROVO
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84604-3354
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:
877-877-6875
Provider Enumeration Date:
03/16/2017

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

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





Copyright © 2007-2024 www.npivalidator.com