Healthcare Provider Details

I. General information

NPI: 1356414346
Provider Name (Legal Business Name): PARADISE VALLEY ALLERGY ASSOC LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 03/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20940 N TATUM BLVD STE 205
PHOENIX AZ
85050-7260
US

IV. Provider business mailing address

20940 N TATUM BLVD STE 205
PHOENIX AZ
85050-7260
US

V. Phone/Fax

Practice location:
  • Phone: 480-991-1930
  • Fax: 480-443-8196
Mailing address:
  • Phone: 480-991-1930
  • Fax: 480-443-8196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number11856
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number11856
License Number StateAZ

VIII. Authorized Official

Name: DR. RICHARD GEORGE KEIGHTLEY
Title or Position: CEO
Credential: MD
Phone: 480-991-1930