1487805628 NPI number — MRS. CRYSTAL MARIE HEILIGENTHAL PA

Table of content: MRS. CRYSTAL MARIE HEILIGENTHAL PA (NPI 1487805628)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487805628 NPI number — MRS. CRYSTAL MARIE HEILIGENTHAL PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEILIGENTHAL
Provider First Name:
CRYSTAL
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

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:
1487805628
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 W UTOPIA RD
Provider Second Line Business Mailing Address:
STE. 100
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85027-4171
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-434-6200
Provider Business Mailing Address Fax Number:
623-434-6164

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6320B W UNION HILLS DR
Provider Second Line Business Practice Location Address:
STE B2300
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85308-1376
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-561-9113
Provider Business Practice Location Address Fax Number:
623-561-6148
Provider Enumeration Date:
10/07/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  4296 , 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: 4296 . This is a "LICENSE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com