Healthcare Provider Details

I. General information

NPI: 1508405077
Provider Name (Legal Business Name): MY HOME DOC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2020
Last Update Date: 02/20/2026
Certification Date: 02/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 E NORTHERN AVE STE 105
PHOENIX AZ
85020-3953
US

IV. Provider business mailing address

1825 E NORTHERN AVE STE 105
PHOENIX AZ
85020-3953
US

V. Phone/Fax

Practice location:
  • Phone: 602-469-9466
  • Fax: 480-393-8555
Mailing address:
  • Phone: 602-469-9466
  • Fax: 480-393-8555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: NILESH PATEL
Title or Position: CHIEF MEDICAL DIRECTOR
Credential: MD
Phone: 602-469-9466