1477970192 NPI number — PASSPORT HEALTH HOLDINGS, LLC.

Table of content: (NPI 1477970192)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477970192 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 OHIO, LLC.
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:
1477970192
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2016
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:
29 PLANTATION PARK DR
Provider Second Line Business Practice Location Address:
B100 #117
Provider Business Practice Location Address City Name:
BLUFFTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-909-6551
Provider Business Practice Location Address Fax Number:
480-383-6567
Provider Enumeration Date:
03/19/2014

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: 261Q00000X , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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