Healthcare Provider Details

I. General information

NPI: 1386070076
Provider Name (Legal Business Name): PWW HEALTH CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2013
Last Update Date: 05/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3202 E GREENWAY RD SUITE 1619
PHOENIX AZ
85032-4548
US

IV. Provider business mailing address

1121 E MISSOURI AVE SUITE 100
PHOENIX AZ
85014-2713
US

V. Phone/Fax

Practice location:
  • Phone: 602-482-2282
  • Fax: 602-482-2909
Mailing address:
  • Phone: 602-889-5833
  • Fax: 602-889-5834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. PIERCE WAYCHOFF
Title or Position: SOLE MBR
Credential: DC
Phone: 602-482-2282