Healthcare Provider Details

I. General information

NPI: 1447720370
Provider Name (Legal Business Name): AKOS LIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2018
Last Update Date: 12/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 S VAL VISTA DR
GILBERT AZ
85296-1376
US

IV. Provider business mailing address

PO BOX 41638
PHOENIX AZ
85080-1638
US

V. Phone/Fax

Practice location:
  • Phone: 602-899-4404
  • Fax:
Mailing address:
  • Phone: 602-899-4404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DESERIE TSOSIE
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 602-935-6389