Healthcare Provider Details

I. General information

NPI: 1508331398
Provider Name (Legal Business Name): AZ SOOKSTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2018
Last Update Date: 10/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7800 N 59TH AVE
GLENDALE AZ
85301-7861
US

IV. Provider business mailing address

PO BOX 14814
SCOTTSDALE AZ
85267-4814
US

V. Phone/Fax

Practice location:
  • Phone: 509-205-5571
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: MRS. INSOOK LEE LANDON
Title or Position: OWNER
Credential: RN
Phone: 509-205-5571