Healthcare Provider Details

I. General information

NPI: 1275377483
Provider Name (Legal Business Name): TUMBLEWEED CLUB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2024
Last Update Date: 06/21/2024
Certification Date: 06/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13210 W VAN BUREN ST STE 112
GOODYEAR AZ
85338-1164
US

IV. Provider business mailing address

13210 W VAN BUREN ST STE 112
GOODYEAR AZ
85338-1164
US

V. Phone/Fax

Practice location:
  • Phone: 623-300-2858
  • Fax:
Mailing address:
  • Phone: 623-300-2858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number
License Number State

VIII. Authorized Official

Name: MR. JEREMY JOSEPOH CLARIDGE
Title or Position: OWNER
Credential:
Phone: 623-246-1000