Healthcare Provider Details

I. General information

NPI: 1235865254
Provider Name (Legal Business Name): PONDEROSA PINE HEALTHCARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2022
Last Update Date: 08/01/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3130 E BROADWAY RD
MESA AZ
85204-1740
US

IV. Provider business mailing address

3130 E BROADWAY RD
MESA AZ
85204-1740
US

V. Phone/Fax

Practice location:
  • Phone: 480-924-7777
  • Fax: 480-924-5712
Mailing address:
  • Phone: 480-924-7777
  • Fax: 480-924-5712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: SOON BURNAM
Title or Position: TREASURER
Credential:
Phone: 949-540-1249