1689951212 NPI number — R & D CAMELBACK, LLC

Table of content: ROXANNE DAWN STACY PTA (NPI 1740437599)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689951212 NPI number — R & D CAMELBACK, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
R & D CAMELBACK, 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:
1689951212
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 97429
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:
85060-7429
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-954-0405
Provider Business Mailing Address Fax Number:
602-954-0485

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4901 N 44TH ST
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85018-2782
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-954-0405
Provider Business Practice Location Address Fax Number:
602-954-0485
Provider Enumeration Date:
11/10/2011

Additional Information

Authorized Official

Authorized Official Last Name:
SAAVEDRA
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
602-954-0405

Provider Taxonomy Codes

  • Taxonomy code: 207K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 656074 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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