Healthcare Provider Details

I. General information

NPI: 1902669807
Provider Name (Legal Business Name): AVAYA THERAPY OF ARIZONA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2024
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18185 N 83RD AVE STE 206
GLENDALE AZ
85308-0519
US

IV. Provider business mailing address

18185 N 83RD AVE STE 206
GLENDALE AZ
85308-0519
US

V. Phone/Fax

Practice location:
  • Phone: 708-408-2258
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: ROLANDO ARROJO
Title or Position: MEMBER
Credential:
Phone: 312-404-9639