Healthcare Provider Details

I. General information

NPI: 1376033233
Provider Name (Legal Business Name): PASSPORT HEALTH HOLDINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2018
Last Update Date: 05/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4647 N 32ND STREET SUITE 115 1ST FLOOR
PHOENIX AZ
85018-3346
US

IV. Provider business mailing address

8324 E HARTFORD DR STE 200
SCOTTSDALE AZ
85255-7801
US

V. Phone/Fax

Practice location:
  • Phone: 877-358-8648
  • Fax: 877-877-6875
Mailing address:
  • Phone: 877-358-8648
  • Fax: 877-877-6875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DOUG SHACKELL
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 480-646-9024