Healthcare Provider Details

I. General information

NPI: 1487993986
Provider Name (Legal Business Name): PVAHCS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2013
Last Update Date: 02/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 E INDIAN SCHOOL RD L-104
PHOENIX AZ
85012-1839
US

IV. Provider business mailing address

650 E INDIAN SCHOOL RD L-104
PHOENIX AZ
85012-1839
US

V. Phone/Fax

Practice location:
  • Phone: 602-277-5551
  • Fax: 602-604-3916
Mailing address:
  • Phone: 602-277-5551
  • Fax: 602-604-3916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License NumberLCSW-10015
License Number StateAZ

VIII. Authorized Official

Name: MS. CLARITA ELIZABETH SCHUBACK
Title or Position: SOCIAL WORKER
Credential: LCSW
Phone: 602-277-5551