Healthcare Provider Details

I. General information

NPI: 1154925568
Provider Name (Legal Business Name): MIHAELA PRUNEAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2020
Last Update Date: 05/07/2021
Certification Date: 05/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6403 W SANDRA TER
GLENDALE AZ
85306-1625
US

IV. Provider business mailing address

6403 W SANDRA TER
GLENDALE AZ
85306-1625
US

V. Phone/Fax

Practice location:
  • Phone: 623-882-6545
  • Fax: 623-537-4010
Mailing address:
  • Phone: 623-882-6545
  • Fax: 623-537-4010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL11643H
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: