Healthcare Provider Details

I. General information

NPI: 1285485920
Provider Name (Legal Business Name): ENROUTE PROVIDER SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2024
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17505 N 79TH AVE STE 313A
GLENDALE AZ
85308-8730
US

IV. Provider business mailing address

17505 N 79TH AVE STE 313A
GLENDALE AZ
85308-8730
US

V. Phone/Fax

Practice location:
  • Phone: 623-225-5875
  • Fax:
Mailing address:
  • Phone: 623-225-5875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DUNEDIN HERVIAS
Title or Position: FOUNDER
Credential: MBA, MHA, LSSBB
Phone: 623-225-5875