1801139712 NPI number — HEARTFIT FOR DUTY, LLC

Table of content: (NPI 1801139712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801139712 NPI number — HEARTFIT FOR DUTY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEARTFIT FOR DUTY, 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:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801139712
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
633 E RAY RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85296-4200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-999-7911
Provider Business Mailing Address Fax Number:
480-499-5829

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
633 E RAY RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85296-4200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-999-7911
Provider Business Practice Location Address Fax Number:
480-499-5829
Provider Enumeration Date:
03/28/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JACK
Authorized Official First Name:
KEPRA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
480-999-7911

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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