Healthcare Provider Details

I. General information

NPI: 1275257917
Provider Name (Legal Business Name): ZKALA IC - MYRTLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2022
Last Update Date: 09/27/2022
Certification Date: 09/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7112 N 55TH AVE STE C
GLENDALE AZ
85301-0707
US

IV. Provider business mailing address

8050 N 19TH AVE STE 500
PHOENIX AZ
85021-5160
US

V. Phone/Fax

Practice location:
  • Phone: 602-842-9000
  • Fax:
Mailing address:
  • Phone: 623-842-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAVAN LEE
Title or Position: EXECUTIVE LEADERSHIP
Credential:
Phone: 623-777-8339