Healthcare Provider Details

I. General information

NPI: 1447864202
Provider Name (Legal Business Name): SOMA CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2020
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6944 E BROADWAY RD STE A
MESA AZ
85208-1916
US

IV. Provider business mailing address

6944 E BROADWAY RD STE A
MESA AZ
85208-1916
US

V. Phone/Fax

Practice location:
  • Phone: 480-550-7460
  • Fax: 480-459-2805
Mailing address:
  • Phone: 480-550-7460
  • Fax: 480-459-2805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: RICHARD WADE
Title or Position: DNP/AUTHORIZED OFFICIAL
Credential: DNP
Phone: 480-550-7460