Healthcare Provider Details

I. General information

NPI: 1649086992
Provider Name (Legal Business Name): SCOTT GROUP 010 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2024
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6551 S 43RD LN
LAVEEN AZ
85339-6246
US

IV. Provider business mailing address

15411 W WADDELL RD STE 102-128
SURPRISE AZ
85379-5170
US

V. Phone/Fax

Practice location:
  • Phone: 480-613-7677
  • Fax:
Mailing address:
  • Phone: 480-613-7677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VIII. Authorized Official

Name: GARY A SCOTT
Title or Position: DIRECTOR
Credential: PASTOR
Phone: 480-613-7677