1174046478 NPI number — YOUR ANGEL ON DUTY, LLC

Table of content: (NPI 1174046478)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174046478 NPI number — YOUR ANGEL ON DUTY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
YOUR ANGEL ON 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:
1174046478
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4747 E ELLIOT RD # 29-460
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:
85044-1627
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:
4747 E ELLIOT RD
Provider Second Line Business Practice Location Address:
#29-460
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-352-1461
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/19/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SANFORD-BOOTH
Authorized Official First Name:
MICHELE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
480-352-1461

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 253Z00000X , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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