Healthcare Provider Details

I. General information

NPI: 1205828894
Provider Name (Legal Business Name): PEDIATRIC PERFUSION SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8121 N 18TH WAY
PHOENIX AZ
85020-3965
US

IV. Provider business mailing address

5801 S MCCLINTOCK DR SUITE 110
TEMPE AZ
85283-6002
US

V. Phone/Fax

Practice location:
  • Phone: 602-513-9568
  • Fax:
Mailing address:
  • Phone: 480-777-0607
  • Fax: 480-777-1345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State

VIII. Authorized Official

Name: MR. STEVE VALLETTA
Title or Position: MANAGER
Credential:
Phone: 480-777-0607