Healthcare Provider Details

I. General information

NPI: 1801139712
Provider Name (Legal Business Name): HEARTFIT FOR DUTY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2013
Last Update Date: 03/29/2013
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

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

V. Phone/Fax

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

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 Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KEPRA L JACK
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 480-999-7911