Healthcare Provider Details

I. General information

NPI: 1245979129
Provider Name (Legal Business Name): ANGELS VALLEY LEGS CARE CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2022
Last Update Date: 05/31/2022
Certification Date: 05/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 W THUNDERBIRD RD APT 2069
PHOENIX AZ
85053-8603
US

IV. Provider business mailing address

6739 W CACTUS RD
PEORIA AZ
85381-5311
US

V. Phone/Fax

Practice location:
  • Phone: 520-527-8038
  • Fax: 623-889-0814
Mailing address:
  • Phone: 520-527-8038
  • Fax: 623-889-0814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: JEAN SIMON JOEL EDOUARD
Title or Position: PA, SA-C
Credential:
Phone: 520-527-8038