Healthcare Provider Details

I. General information

NPI: 1659690287
Provider Name (Legal Business Name): EDVENTURES GROUP PINON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2010
Last Update Date: 05/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MILE NORTH OF PINON NAVAJO RT HWY 41
PINON AZ
86510
US

IV. Provider business mailing address

8848 WILLOW HILLS CT
SANDY UT
84093-1889
US

V. Phone/Fax

Practice location:
  • Phone: 520-907-6890
  • Fax: 801-930-9134
Mailing address:
  • Phone: 520-907-6890
  • Fax: 801-930-9134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. SIAMAK KHADJENOURY
Title or Position: CEO
Credential:
Phone: 520-907-6890