Healthcare Provider Details

I. General information

NPI: 1578853065
Provider Name (Legal Business Name): BASELINE DISTRIBUTING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2011
Last Update Date: 09/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 E HARWELL RD
PHOENIX AZ
85042-6605
US

IV. Provider business mailing address

920 E HARWELL RD
PHOENIX AZ
85042-6605
US

V. Phone/Fax

Practice location:
  • Phone: 602-908-2667
  • Fax:
Mailing address:
  • Phone: 602-908-2667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. RYAN DEAN PALMER
Title or Position: MANAGER
Credential:
Phone: 602-908-2667