1083060594 NPI number — DPAC HOLDINGS LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083060594 NPI number — DPAC HOLDINGS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DPAC 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:
DESERT PALM ADULT CARE
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:
1083060594
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1214 E PALMAIRE 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:
85020-5429
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:
1214 E PALMAIRE DR
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:
85020-5429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-943-4842
Provider Business Practice Location Address Fax Number:
877-867-5390
Provider Enumeration Date:
05/13/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GONZVAR
Authorized Official First Name:
JEAN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
480-331-8495

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  AL9483H , 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)

  • Identifier: 476089 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".