Healthcare Provider Details

I. General information

NPI: 1780215681
Provider Name (Legal Business Name): SIP HOME SYSTEMS - MESA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2020
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24TH AT CAMELBACK, 2375 E. CAMELBACK RD. SUITE 600
PHOENIX AZ
85016
US

IV. Provider business mailing address

24TH AT CAMELBACK, 2375 E. CAMELBACK RD. SUITE 600
PHOENIX AZ
85016-2111
US

V. Phone/Fax

Practice location:
  • Phone: 623-374-7774
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: KENNY MAI
Title or Position: MD
Credential:
Phone: 623-374-7774