Healthcare Provider Details

I. General information

NPI: 1114233079
Provider Name (Legal Business Name): 1203 PALLOVERDE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2010
Last Update Date: 08/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 W PALO VERDE DR
CHANDLER AZ
85224-2358
US

IV. Provider business mailing address

1203 W PALO VERDE DR
CHANDLER AZ
85224-2358
US

V. Phone/Fax

Practice location:
  • Phone: 202-288-0422
  • Fax:
Mailing address:
  • Phone: 202-288-0422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License NumberAL7815H
License Number StateAZ

VIII. Authorized Official

Name: MR. BRIAN HACKETT
Title or Position: PRESIDENT
Credential:
Phone: 202-288-0422