Healthcare Provider Details

I. General information

NPI: 1831711258
Provider Name (Legal Business Name): HARBOR HEALTH INTEGRATED CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2020
Last Update Date: 08/31/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 W NORTHERN AVE STE 200
PHOENIX AZ
85021-5478
US

IV. Provider business mailing address

1717 W NORTHERN AVE STE 200
PHOENIX AZ
85021-5478
US

V. Phone/Fax

Practice location:
  • Phone: 888-900-8082
  • Fax:
Mailing address:
  • Phone: 888-900-8082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHNWICK NATHAN
Title or Position: OWNER
Credential:
Phone: 888-900-8082