Healthcare Provider Details

I. General information

NPI: 1518382787
Provider Name (Legal Business Name): FIESTA HEALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2014
Last Update Date: 10/14/2022
Certification Date: 10/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 S LONGMORE STE 8
MESA AZ
85202-9607
US

IV. Provider business mailing address

1303 S LONGMORE STE 8
MESA AZ
85202-9607
US

V. Phone/Fax

Practice location:
  • Phone: 480-649-5297
  • Fax: 480-649-1790
Mailing address:
  • Phone: 480-649-5297
  • Fax: 480-649-1790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: ADAM WINTER
Title or Position: BILLING MANAGER
Credential:
Phone: 602-577-8836