Healthcare Provider Details

I. General information

NPI: 1417841800
Provider Name (Legal Business Name): DESERT IV THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2025
Last Update Date: 10/16/2025
Certification Date: 10/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 E PALM LN STE 205
PHOENIX AZ
85004-1555
US

IV. Provider business mailing address

423 W GARY WAY
PHOENIX AZ
85041-8031
US

V. Phone/Fax

Practice location:
  • Phone: 602-652-2962
  • Fax: 800-572-2262
Mailing address:
  • Phone: 602-471-2188
  • Fax: 800-572-2262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: PERLA E PUEBLA
Title or Position: OWNER
Credential: FNP
Phone: 602-471-2188