MEDICARE: VALLEY DIRECT PRIMARY CARE, PLLC

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1457978215
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VALLEY DIRECT PRIMARY CARE, PLLC

Provider Business Mailing Address
First Line	:	13970 W WOODBRIDGE AVE
Second Line	:
City	:	GOODYEAR
State	:	AZ
Zip	:	85395-1485
Country	:	US
Telephone Number	:	623-562-0130
Fax Number	:

Provider Business Practice Location Address
First Line	:	9240 W UNION HILLS DR STE 100
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85382-8213
Country	:	US
Telephone Number	:	623-562-0130
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TARUN BASSI
Credential	:	MD
Telephone Number	:	623-562-0130

Provider Enumeration Date	:	06/28/2020
Last Update Date	:	08/06/2020

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