Healthcare Provider Details

I. General information

NPI: 1255081139
Provider Name (Legal Business Name): LOFA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2022
Last Update Date: 03/24/2022
Certification Date: 03/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7440 W CACTUS RD STE A19
PEORIA AZ
85381-9534
US

IV. Provider business mailing address

6781 W GELDING DR
PEORIA AZ
85381-4717
US

V. Phone/Fax

Practice location:
  • Phone: 480-307-7275
  • Fax:
Mailing address:
  • Phone: 480-307-7275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. LAYTH JARULLAH
Title or Position: OWNER
Credential:
Phone: 480-307-7275