Healthcare Provider Details

I. General information

NPI: 1205525839
Provider Name (Legal Business Name): PHOENIX HEALTH PRACTITIONERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 05/03/2024
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4222 N 12TH ST STE 200
PHOENIX AZ
85014-6024
US

IV. Provider business mailing address

12474 W FOREST PLEASANT PL
PEORIA AZ
85383-5666
US

V. Phone/Fax

Practice location:
  • Phone: 602-795-9223
  • Fax: 602-795-9728
Mailing address:
  • Phone: 602-795-9223
  • Fax: 602-795-9728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: NEHEMIAH ABUGA
Title or Position: OWNER
Credential:
Phone: 480-450-5020