1962726059 NPI number — AVELLA OF DEER VALLEY, INC

Table of content: (NPI 1962726059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962726059 NPI number — AVELLA OF DEER VALLEY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVELLA OF DEER VALLEY, INC
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:
AVELLA OF DEER VALLEY-SECOND
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:
1962726059
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/14/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24416 N. 19TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85085
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-434-1700
Provider Business Mailing Address Fax Number:
623-742-1705

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24416 N 19TH AVE
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:
85085-1887
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-719-6349
Provider Business Practice Location Address Fax Number:
877-719-6362
Provider Enumeration Date:
03/18/2010

Additional Information

Authorized Official

Authorized Official Last Name:
OBERG
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT SECRETARY
Authorized Official Telephone Number:
952-936-1300

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336M0002X , with the licence number: Y005084 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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