1124225008 NPI number — BACK IN ACTION OF SCOTTSDALE LLC

Table of content: (NPI 1124225008)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124225008 NPI number — BACK IN ACTION OF SCOTTSDALE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BACK IN ACTION OF SCOTTSDALE 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:
6
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:
1124225008
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8711 E PINNACLE PEAK RD PMB 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCOTTSDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85255-3517
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-513-4801
Provider Business Mailing Address Fax Number:
480-513-4867

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2340 E BEARDSLEY RD STE 120
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:
85024-1286
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-513-4801
Provider Business Practice Location Address Fax Number:
480-513-4867
Provider Enumeration Date:
07/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FANDRY
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
W
Authorized Official Title or Position:
CLINICAL DIRECTOR
Authorized Official Telephone Number:
480-513-4801

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 437521 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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