Healthcare Provider Details

I. General information

NPI: 1326197500
Provider Name (Legal Business Name): PROFESSIONAL NUTRITION SYSTEMS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 N 16TH ST SUITE 140 ROOM 1
PHOENIX AZ
85020-4431
US

IV. Provider business mailing address

7600 N 16TH ST SUITE 140 ROOM 1
PHOENIX AZ
85020-4431
US

V. Phone/Fax

Practice location:
  • Phone: 480-897-2260
  • Fax: 480-897-2274
Mailing address:
  • Phone: 480-897-2260
  • Fax: 480-897-2274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number State

VIII. Authorized Official

Name: REBECCA S POLMANTEER
Title or Position: MANAGER
Credential:
Phone: 480-897-2260