Healthcare Provider Details

I. General information

NPI: 1295009561
Provider Name (Legal Business Name): HEARTFIT FOR DUTY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 04/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 E RAY RD SUITE 101
GILBERT AZ
85296-4200
US

IV. Provider business mailing address

4192 E PALM BEACH DR
CHANDLER AZ
85249-7398
US

V. Phone/Fax

Practice location:
  • Phone: 480-999-7911
  • Fax: 480-499-5829
Mailing address:
  • Phone: 602-402-5090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP3059
License Number StateAZ

VIII. Authorized Official

Name: MRS. KEPRA L JACK
Title or Position: DIRECTOR OF OPERATIONS
Credential: RN
Phone: 602-402-5090