MEDICARE: ETERNITY SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1013646678
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ETERNITY SERVICES LLC

Provider Business Mailing Address
First Line	:	2925 W MYRTLE AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85051-7538
Country	:	US
Telephone Number	:	602-621-5126
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 W BETHANY HOME RD STE 1
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85015-1937
Country	:	US
Telephone Number	:	602-601-4104
Fax Number	:

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	DERRICK MONTGOMERY
Credential	:
Telephone Number	:	602-621-5126

Provider Enumeration Date	:	06/08/2022
Last Update Date	:	06/08/2022

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Directions to “ETERNITY SERVICES LLC ” Practice Location

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