Healthcare Provider Details

I. General information

NPI: 1265930614
Provider Name (Legal Business Name): DESERT RIDGE MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2018
Last Update Date: 01/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26224 N TATUM BLVD STE 11
PHOENIX AZ
85050-7500
US

IV. Provider business mailing address

3724 N 3RD ST STE 301
PHOENIX AZ
85012-2035
US

V. Phone/Fax

Practice location:
  • Phone: 480-634-6400
  • Fax: 480-404-9649
Mailing address:
  • Phone: 480-634-6400
  • Fax: 480-404-9649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. CHALLEN WAYCHOFF III
Title or Position: COO/MANAGER
Credential:
Phone: 480-634-6400