Healthcare Provider Details

I. General information

NPI: 1184346405
Provider Name (Legal Business Name): PROUDLY ARIZONA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2022
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 W NORTHERN AVE STE 106
PHOENIX AZ
85021-5400
US

IV. Provider business mailing address

4816 W BETHANY HOME RD APT 90
GLENDALE AZ
85301-5233
US

V. Phone/Fax

Practice location:
  • Phone: 323-378-8797
  • Fax:
Mailing address:
  • Phone: 323-378-8797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code342000000X
TaxonomyTransportation Network Company
License Number
License Number StateNULL

VIII. Authorized Official

Name: ESRA A KHALEEL
Title or Position: OWNER/MANAGER
Credential: MS
Phone: 323-378-8797