Healthcare Provider Details

I. General information

NPI: 1568853752
Provider Name (Legal Business Name): SEEDS OF GAIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2015
Last Update Date: 02/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 S MESA DR UNIT 142
MESA AZ
85210-2711
US

IV. Provider business mailing address

PO BOX 4252
MESA AZ
85211-4252
US

V. Phone/Fax

Practice location:
  • Phone: 480-277-0313
  • Fax:
Mailing address:
  • Phone: 480-277-0313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number957399
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number957399
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number957399
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number957399
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number957399
License Number StateAZ
# 6
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number957399
License Number StateAZ
# 7
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number957399
License Number StateAZ
# 8
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number957399
License Number StateAZ
# 9
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number957399
License Number StateAZ
# 10
Primary TaxonomyN
Taxonomy Code385HR2050X
TaxonomyRespite Care Camp
License Number957399
License Number StateAZ
# 11
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number957399
License Number StateAZ
# 12
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number957399
License Number StateAZ
# 13
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number957399
License Number StateAZ
# 14
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number957399
License Number StateAZ

VIII. Authorized Official

Name: MOISE KELLY
Title or Position: PRESIDENT
Credential:
Phone: 480-277-0313