Healthcare Provider Details

I. General information

NPI: 1285242560
Provider Name (Legal Business Name): GROWING SPACE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2020
Last Update Date: 07/22/2020
Certification Date: 07/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3940 S 79TH DR
PHOENIX AZ
85043-1694
US

IV. Provider business mailing address

3940 S 79TH DR
PHOENIX AZ
85043-1694
US

V. Phone/Fax

Practice location:
  • Phone: 480-347-8265
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOURNE DOMEK
Title or Position: OCCUPATIONAL THERAPIST
Credential: OTL
Phone: 480-347-8265