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NPI Code Detail

MEDICARE: PROUDLY ARIZONA LLC

MEDICARE: PROUDLY ARIZONA 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
1342000000XTransportation Network Company
2343900000XNon-emergency Medical Transport (VAN)

General Provider Information

NPI Number : 1184346405
Entity Type Code : Organization
Provider Name (Legal Business Name) : PROUDLY ARIZONA LLC
Provider Business Mailing Address
First Line : 4816 W BETHANY HOME RD APT 90
Second Line :
City : GLENDALE
State : AZ
Zip : 85301-5233
Country : US
Telephone Number : 323-378-8797
Fax Number :
Provider Business Practice Location Address
First Line : 1717 W NORTHERN AVE STE 106
Second Line :
City : PHOENIX
State : AZ
Zip : 85021-5400
Country : US
Telephone Number : 323-378-8797
Fax Number :
Authorized Official
Title or Position : OWNER/MANAGER
Name : ESRA A KHALEEL
Credential : MS
Telephone Number : 323-378-8797
Provider Enumeration Date : 09/13/2022
Last Update Date : 09/13/2022

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Directions to “PROUDLY ARIZONA LLC ” Practice Location

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